Muller Journal of Medical Sciences and Research

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

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


Namhun Jong, Songil Rim, Hyesong Kim 
 Department of Gastroenterology, Pyongyang Medical College Hospital, Kim II Sung University, Pyongyang, Democratic People's Republic of Korea

Correspondence Address:
Dr. Hyesong Kim
Department of Gastroenterology, Pyongyang Medical College Hospital, Kim II Sung University, Pyongyang
Democratic People's Republic of Korea

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.



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;10:21-25


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 Jun 25 ];10:21-25
Available from: http://www.mjmsr.net/text.asp?2019/10/1/21/259248


Full Text



 Introduction



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



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 normalComputed 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 painChange in the color of peritoneal fluid (clear fluid)Improvement in the number of SIRS components (SIRS score) to one or less.

Clinical parameters

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 groupsMortality rate, the incidence of local complications and length of hospital stay were compared between two groupsDuration of peritoneal lavage in study groupSeverity scores at the onset of the disease in both groups (CT severity index, Bedside index of severity in AP)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



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}

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}

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}

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



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



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.

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