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ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 21-25

Clinical effectiveness of continuous peritoneal lavage in moderately severe to severe acute pancreatitis


Department of Gastroenterology, Pyongyang Medical College Hospital, Kim II Sung University, Pyongyang, Democratic People's Republic of Korea

Date of Web Publication29-May-2019

Correspondence Address:
Dr. Hyesong Kim
Department of Gastroenterology, Pyongyang Medical College Hospital, Kim II Sung University, Pyongyang
Democratic People's Republic of Korea
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjmsr.mjmsr_14_18

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  Abstract 


Purpose: This study aims to evaluate the clinical effectiveness of continuous peritoneal lavage in moderately severe to severe acute pancreatitis (AP). Materials and Methods: We studied 58 patients with moderately severe to severe AP who were admitted from January 2015 to April 2017. Among these patients, 31 patients were treated only conventional therapy (control group). Twenty-seven patients were received continuous peritoneal lavage with conventional therapy (study group). Laboratory parameters and severity scores were compared before and 7 days after therapy between two groups. Mortality rate, the incidence of local complications and length of hospital stay were also compared between two groups. Results: There were no adverse events (bowel perforation and bleeding) associated with abdominal paracentesis for peritoneal lavage. The level of all parameters (white blood cell [WBC], C reactive protein [CRP], serum amylase, lactate dehydrogenase [LDH], blood glucose, serum creatinine, base excess, and serum calcium) and all the severity scores (systemic inflammatory response syndrome [SIRS], Marshall) were significantly improved 7 days after treatment compared before therapy in two groups (P < 0.05). We also compared the level of all laboratory parameters and severity scores between two groups 7 days after therapy. The level of serum amylase, blood glucose, and serum calcium was similar between two groups 7 days after treatment. In the study group, the level of WBC, CRP, LDH, serum creatinine, base excess, and severity scores (SIRS, Marshall) was significantly improved compared with control group 7 days after therapy (P < 0.05). Mortality rate was significantly decreased in the study group compared with control group (7.4% vs. 16.1%, P < 0.01). The incidence of local complication had also a significant difference between two groups (22.2% vs. 35.5%, P < 0.05). The length of hospital stay was significantly reduced in the study group compared with control group (33.1 ± 28.0 vs. 48.9 ± 36.2 days, P < 0.01). Conclusion: Continuous peritoneal lavage can significantly reduce mortality, complications, and length of hospital stay in moderately severe to severe AP.

Keywords: Acute pancreatitis, peritoneal lavage, pancreatic ascites


How to cite this article:
Jong N, Rim S, Kim H. Clinical effectiveness of continuous peritoneal lavage in moderately severe to severe acute pancreatitis. Muller J Med Sci Res 2019;10:21-5

How to cite this URL:
Jong N, Rim S, Kim H. Clinical effectiveness of continuous peritoneal lavage in moderately severe to severe acute pancreatitis. Muller J Med Sci Res [serial online] 2019 [cited 2019 Aug 21];10:21-5. Available from: http://www.mjmsr.net/text.asp?2019/10/1/21/259248




  Introduction Top


Acute pancreatitis (AP) is one of the most common gastrointestinal disorders requiring acute hospitalization with an annual incidence of 4.9–73.4 cases per 100,000 persons.[1],[2],[3],[4]

It has a mild, self-limiting course in 80% of patients who recover without complications.

The remaining patients have a severe disease with local and systemic complications, and this disease carries a high mortality risk.[5]

The clinical course of AP is largely divided into two phases. The early phase (within the 1st week) is characterized by the development of the systemic inflammatory response syndrome (SIRS) and organ failure. The late phase (>1 week) is characterized by local complications.

During the early phase, death occurs as a result of organ failure and the deaths of late phase are due to infected necrosis.[6]

Peritoneal lavage was introduced in the treatment of AP, based on the theory that the elimination of ascites containing inflammatory cytokines and infectious mediators decrease the inflammation and the severity of the disease.[7]

The removal of peritoneal ascites in the early phase decreases the severity of AP and the need of surgical intervention. These data suggest that a step up approach containing peritoneal lavage could be beneficial.[8]

Another benefit of peritoneal lavage is to decrease the intra-abdominal pressure (IAP).[9] Therefore, we estimated clinical effectiveness of continuous peritoneal lavage in the treatment of moderately severe to severe AP.


  Materials and Methods Top


Study population

We studied 58 patients with moderately severe to severe AP who were admitted from January 2013 to April 2017. Among these patients, 31 patients were treated only conventional therapy (control group). Twenty-seven patients were received peritoneal lavage with conventional therapy (study group). The diagnosis of AP was made according to the presence of two of the following three manifestations:[10]

  • Abdominal pain (acute onset of severe epigastric pain often radiating to the back)
  • Elevated serum amylase levels at least three times greater than the upper limit of normal
  • Computed tomography (CT) findings suggesting AP (enlargement of the pancreas, an uneven density of the pancreatic parenchyma, an increased concentration of adipose tissue in the parapancreatic and retroperitoneal cavities and mesenterium and fluid collection).


The severity of AP was based on the revised Atlanta classification.[10],[11] All patients (study + control group) had pancreatic ascites in more than one location (location; perisplenic, perihepatic, interloop, or pelvis) on ultrasonography.

Methods

Treatments

In control group, all patients were treated only conventional therapy. Conventional therapy included enteral nutrition, gastrointestinal decompression, antibiotics, fluid resuscitation, suppressing gastric acid, and pain relievers. In the study group, all patients received peritoneal lavage with conventional therapy. A catheter for peritoneal lavage was inserted into peritoneal cavity at the site 1 cm away lateral left rectus muscle of the abdomen using a 1–1.5 cm incision under local infiltration anesthesia. The fluid used was normal saline, and ciprofloxacin 400 mg and metronidazole 500 mg were added once a day. A volume of 4 L of the fluid was run into the peritoneal cavity under gravity and drained out by gravity continuously within 24 h.

Peritoneal lavage ended when the following manifestations were observed:

  • Relief of abdominal pain
  • Change in the color of peritoneal fluid (clear fluid)
  • Improvement in the number of SIRS components (SIRS score) to one or less.


Clinical parameters

  1. Laboratory parameters (white blood cell [WBC], C reactive protein [CRP], base excess, serum amylase, lactate dehydrogenase [LDH], blood glucose, creatinine, and serum calcium) and severity scores (SIRS and Marshall) were compared before and 7 days after therapy between two groups
  2. Mortality rate, the incidence of local complications and length of hospital stay were compared between two groups
  3. Duration of peritoneal lavage in study group
  4. Severity scores at the onset of the disease in both groups (CT severity index, Bedside index of severity in AP)
  5. Demographic data in both groups (age, sex, and etiology).


Statistics analysis

We used the SPSS statistical program (release 13.0.1 J, SPSS, Inc., Chicago, IL, USA) for the statistical analysis. Continuous variables are expressed as medians and ranges. The Wilcoxon test was used to evaluate the significance of differences in the continuous variables between paired samples. Differences in continuous variables were evaluated using the Mann–Whitney U-test between two unpaired samples. Dichotomous variables were compared using the Chi-square test.

P < 0.05 was considered as statistically significant.


  Results Top


Clinical characteristics of the study population

Patient's characteristics were shown in [Table 1]. There was no significant difference in age, sex, and etiology between two groups. There was also no significant difference in disease severity between two groups. There were no adverse events (bowel perforation and bleeding) associated with abdominal paracentesis for peritoneal lavage. The median (±standard deviation) duration of peritoneal lavage was 5.9 (±2.23) days in the study group.
Table 1: Clinical characteristics of the study population

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Changes in laboratory parameters and severity scores

There were no significant differences in all laboratory parameters and severity scores between two groups before therapy [Table 2]. The level of all laboratory parameters (WBC, CRP, serum amylase, LDH, blood glucose, creatinine, base excess, and serum calcium) was significantly improved 7 days after treatment compared with before therapy in two groups (P < 0.05). All the severity scores (SIRS, Marshall) were also significantly decreased 7 days after treatment compared with before therapy in two groups (P < 0.05).
Table 2: Laboratory parameters and severity score before and 7 days after treatment in two groups

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We also compared the level of all laboratory parameters and severity scores between two groups 7 days after therapy. The level of serum amylase, blood glucose, and serum calcium was similar between two groups 7 days after treatment. In study group, the level of WBC, CRP, LDH, serum creatinine, base excess, and severity scores (SIRS, Marshall) was significantly improved compared with control group 7 days after therapy (P < 0.05).

Outcomes

Mortality rate was significantly decreased in study group compared with control group (7.4% vs. 16.1%, P < 0.01) [Table 3]. In study group, one patient died due to secondary sepsis caused by infected necrosis. The other patient died due to deterioration of comorbidity (myocardial infarction). In control group, three patients died of organ failure (two cases - renal failure and one case - multiple organ failure). Two patients succumbed to uncontrolled sepsis. The incidence of local complications had also a significant difference between two groups (22.2% vs. 35.5%, P < 0.05) [Table 3]. In study group according to the step up approach, four patients (infected acute necrotic collection [ANC] and Walled-off necrosis [WON], symptomatic WON) received ultrasound-guided percutaneous catheter drainage (PCD) when there was a feasible pathway for PCD.
Table 3: Clinical outcomes of the study population

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The surgical drainage was performed in one patient when there was no feasible pathway under ultrasound. One patient received open surgery due to bowel complication (ileus) at the 43rd day of AP onset. In control group, seven patients (infected ANC and WON) received ultrasound-guided PCD when there was a feasible pathway for PCD.

Surgical drainage was performed in four patients when there was no feasible pathway under ultrasound. The length of hospital stay was significantly reduced in the study group compared with control group (33.1 ± 28.0 vs. 48.9 ± 36.2 days, P < 0.01) [Table 3].


  Discussion Top


About 80% of AP patients have mild self-limiting course without complications. The remaining patients have severe AP with local and systemic complications. Peritoneal fluid in the early course of AP contains activated pancreatic enzymes, inflammatory cytokines, and vascular endotoxin, which are absorbed into peritoneum and deteriorate SIRS.[12],[13] Thereby evacuating peritoneal fluid during the early phase could be beneficial in patients with severe AP. Based on this theory, we performed peritoneal lavage in patients with moderately severe to severe AP. In our study, the puncture site was 1 cm away lateral left rectus muscle of the abdomen unlike other literatures (Douglas pouch) to prevent adverse event including bowel injury without using ultrasound. [14,15] In fact, there were no adverse events (bowel perforation and bleeding) associated with abdominal paracentesis for peritoneal lavage. Laboratory parameters (WBC, CRP, serum amylase, LDH, blood glucose, creatinine, base excess, and serum calcium) and the severity scores (SIRS, Marshall) were significantly improved 7 days after therapy in two groups. Especially in study group, the level of WBC, CRP, LDH, serum creatinine, base excess, and severity scores (SIRS, Marshall) was significantly improved compared with control group 7 days after therapy (P < 0.05). Significant improvement of inflammatory parameters (WBC, CRP, and SIRS) suggests anti-inflammatory effect of peritoneal lavage, and it is in line with the previous report.[16] Serum creatinine is the unique factor to reflect kidney function, and base excess is a parameter to evaluate respiratory function.

A significant change of serum creatinine and base excess suggests that peritoneal lavage can improve visceral blood supplement and organ dysfunction (lung and kidney) by reducing IAP. In fact, peritoneal lavage is the first choice minimally intervention of decreasing IAP.[17],[18] In study group, mortality rate (7.4%) was significant statistically decreased compared with the study group (16.1%, P < 0.01). In study group, no patient died due to organ failure. However, in control group, three cases died of single or multiple organ failure. It suggests that peritoneal lavage decrease the severity of the disease process and improve multiple organ failure by evacuating inflammatory cytokines. In the study group, 6 (22.2%) patients required ultrasound-guided or surgical intervention due to local complications whereas 11 (35.5%) patients had local complications required intervention in control group. It was statistically significant (P < 0.05). In the course of AP anti-inflammatory, cytokines are concomitantly produced leading to a compensatory response syndrome (CARS) with the release of proinflammatory mediators, which leads to infectious complication.[19],[20] We suppose that peritoneal lavage can decrease the incidence of infectious complications by suppressing the SIRS and CARS.


  Conclusion Top


Continuous peritoneal lavage can significantly reduce mortality, complications, and length of hospital stay in moderately severe to severe AP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, Bulsiewicz WJ, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012;143:1179-87.  Back to cited text no. 1
    
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Fagenholz PJ, Fernández-del Castillo C, Harris NS, Pelletier AJ, Camargo CA Jr. Direct medical costs of acute pancreatitis hospitalizations in the United States. Pancreas 2007;35:302-7.  Back to cited text no. 2
    
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Fagenholz PJ, Castillo CF, Harris NS, Pelletier AJ, Camargo CA Jr. Increasing United States hospital admissions for acute pancreatitis, 1988-2003. Ann Epidemiol 2007;17:491-7.  Back to cited text no. 3
    
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Yadav D, Lowenfels AB. Trends in the epidemiology of the first attack of acute pancreatitis: A systematic review. Pancreas 2006;33:323-30.  Back to cited text no. 4
    
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Ranson JH, Berman RS. Long peritoneal lavage decreases pancreatic sepsis in acute pancreatitis. Ann Surg 1990;211:708-16.  Back to cited text no. 7
    
8.
Liu WH, Ren LN, Chen T, Liu LY, Jiang JH, Wang T, et al. Abdominal paracentesis drainage ahead of percutaneous catheter drainage benefits patients attacked by acute pancreatitis with fluid collections: A retrospective clinical cohort study. Crit Care Med 2015;43:109-19.  Back to cited text no. 8
    
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Maraví-Poma E, Jiménez I, Martínez JM, Escuchuri J, Izura J. Abdominal compartmental syndrome, severe acute pancreatitis an percutaneos decompressive peritoneal. Intensive Care Med 2003;29:185.  Back to cited text no. 9
    
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Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis – 2012: Revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-11.  Back to cited text no. 10
    
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American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992;20:864-74.  Back to cited text no. 11
    
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Fujita M, Masamune A, Satoh A, Sakai Y, Satoh K, Shimosegawa T, et al. Ascites of rat experimental model of severe acute pancreatitis induces lung injury. Pancreas 2001;22:409-18.  Back to cited text no. 12
    
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Baudin G, Chassang M, Gelsi E, Novellas S, Bernardin G, Hébuterne X, et al. CT-guided percutaneous catheter drainage of acute infectious necrotizing pancreatitis: Assessment of effectiveness and safety. AJR Am J Roentgenol 2012;199:192-9.  Back to cited text no. 13
    
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Liu WH, Wang T, Yan HT, Chen T, Xu C, Ye P, et al. Predictors of percutaneous catheter drainage (PCD) after abdominal paracentesis drainage (APD) in patients with moderately severe or severe acute pancreatitis along with fluid collections. PLoS One 2015;10:e0115348.  Back to cited text no. 14
    
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Matsumoto K, Miyake Y, Nakatsu M, Toyokawa T, Ando M, Hirohata M, et al. Usefulness of early-phase peritoneal lavage for treating severe acute pancreatitis. Intern Med 2014;53:1-6.  Back to cited text no. 15
    
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Souza LJ, Coelho AM, Sampietre SN, Martins JO, Cunha JE, Machado MC, et al. Anti-inflammatory effects of peritoneal lavage in acute pancreatitis. Pancreas 2010;39:1180-4.  Back to cited text no. 16
    
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Maraví-Poma E, Jiménez I, Martínez JM, Escuchuri J, Izura J. Abdominal compartmental syndrome, severe acute pancreatitis and percutaneos decompressive peritoneal. Intensive Care Med 2003;29:S185.  Back to cited text no. 17
    
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Dambrauskas Z, Parseliūnas A, Maleckas A, Gulbinas A, Barauskas G, Pundzius J, et al. Interventional and surgical management of abdominal compartment syndrome in severe acute pancreatitis. Medicina (Kaunas) 2010;46:249-55.  Back to cited text no. 18
    
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Bone RC. Sir Isaac newton, sepsis, SIRS, and CARS. Crit Care Med 1996;24:1125-8.  Back to cited text no. 19
    
20.
Mentula P, Kylänpää ML, Kemppainen E, Jansson SE, Sarna S, Puolakkainen P, et al. Plasma anti-inflammatory cytokines and monocyte human leucocyte antigen-DR expression in patients with acute pancreatitis. Scand J Gastroenterol 2004;39:178-87.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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