Evidence-based treatment of acute pancreatitis: a look at established paradigms.
BACKGROUND
The management of acute pancreatitis (AP) is still based on speculative and unproven paradigms in many centers. Therefore, we performed an evidence-based analysis to assess the best available treatment.


METHODS
A comprehensive Medline and Cochrane Library search was performed evaluating the indication and timing of interventional and surgical approaches, and the value of aprotinin, lexipafant, gabexate mesylate, and octreotide treatment. Each study was ranked according to the evidence-based methodology of Sackett; whenever feasible, we performed new meta-analyses using the random-effects model. Recommendations were based on the available level of evidence (A=large randomized; B=small randomized; C=prospective trial).


RESULTS
None of the evaluated medical treatments is recommended (level A). Patients with AP should receive early enteral nutrition (level B). While mild biliary AP is best treated by primary cholecystectomy (level B), patients with severe biliary AP require emergency endoscopic papillotomy followed by interval cholecystectomy (level A). Patients with necrotizing AP should receive imipenem or meropenem prophylaxis to decrease the risk of infected necrosis and mortality (level A). Sterile necrosis per se is not an indication for surgery (level C), and not all patients with infected necrosis require immediate surgery (level B). In general, early necrosectomy should be avoided (level B), and single necrosectomy with postoperative lavage should be preferred over "open-packing" because of fewer complications with comparable mortality rates (level C).


CONCLUSIONS
While providing new insights into key aspects of AP management, this evidence-based analysis highlights the need for further clinical trials, particularly regarding the indications for antibiotic prophylaxis and surgery.
Heinrich
Stefan
S
Swiss HPB Center, Department of Visceral and Transplantation Surgery, University Hospital of Zurich, Zurich, Switzerland.
Schäfer
Markus
M
Rousson
Valentin
V
Clavien
Pierre-Alain
PA
D000208:Acute Disease; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis; D007611:Aprotinin / Q000627:therapeutic use; D002763:Cholecystectomy; D004750:Enteral Nutrition; D019317:Evidence-Based Medicine; D016670:Gabexate / Q000627:therapeutic use; D005765:Gastrointestinal Agents / Q000627:therapeutic use; D006801:Humans; D007093:Imidazoles / Q000627:therapeutic use; D015378:Imipenem / Q000627:therapeutic use; D007930:Leucine / Q000031:analogs & derivatives / Q000627:therapeutic use; D000077731:Meropenem; D015282:Octreotide / Q000627:therapeutic use; D010195:Pancreatitis / Q000188:drug therapy / Q000601:surgery*; D019283:Pancreatitis, Acute Necrotizing / Q000188:drug therapy / Q000601:surgery; D010972:Platelet Activating Factor / Q000037:antagonists & inhibitors; D016032:Randomized Controlled Trials as Topic; D015842:Serine Proteinase Inhibitors / Q000627:therapeutic use; D016717:Sphincterotomy, Endoscopic; D013845:Thienamycins / Q000627:therapeutic use
D000900:Anti-Bacterial Agents; D005765:Gastrointestinal Agents; D007093:Imidazoles; D010972:Platelet Activating Factor; D015842:Serine Proteinase Inhibitors; D013845:Thienamycins; D016670:Gabexate; D015378:Imipenem; D007611:Aprotinin; D000077731:Meropenem; D007930:Leucine; C103289:lexipafant; D015282:Octreotide