Multidisciplinary approach for severe acute pancreatitis in a low-volume

Introduction: Acute pancreatitis is one of the most frequent reasons for hospital admittance due to bilio-pancreatic diseases (1-2). The main etiologies of acute pancreatitis are biliary and alcohol consumption although in other cases the origin of the disease is unknown (3). Most of the patients have an uneventful course but up to 25 % of all patients with acute pancreatitis develop severe complications and are classified as severe pancreatitis with an associated death rate up to 30-50% (2-4). Treatment of acute pancreatitis and in particular severe acute pancreatitis (SAP) has progressively evolved and improved. Probably one of the reasons for this improvement is the fact that step by step algorithms have been incorporated to the decision-making process (5-6). Similarly, a step-up approach has been proposed for pancreatic necrosis (7). In order to offer treatment in accordance to the severity of the disease, we need to obtain an accurate view of the expected evolution and prognosis. For that purpose, patients have to be stratified on the bases of standard classifications. One of the first classifications is the Ranson criteria that includes several laboratory and clinical data to obtain an estimated mortality (8-9). Radiological features observed on CT-scan that consider pancreatic necrosis and the appearance of the pancreas point out an estimated mortality rate (10). Simplified acute physiology score version 3 (SAPS 3) is a mathematical model that provides predicted mortality and is widely used in ICUs. It is a useful index for severely ill patients (11). The revised Atlanta classification of acute pancreatitis provides a graduation of two phases of the disease: early and late phases and severity is classified as mild, moderate or severe by using clinical and radiologic features (5-12). As mortality of severe pancreatitis is usually high, patients are expected to undergo long intensive care unit (ICU) and hospital stay. Beside medical treatment for single or multiple organ failure, various complications may require percutaneous, endoscopic or surgical procedures. In some circumstances, major complications have to be addressed in order to improve outcomes in terms of morbid-mortality. Although surgical procedures are unlikely, surgery is required for abdominal sepsis due to hollow viscera necrosis/perforation or persistent abdominal sepsis spite medical treatment and percutaneous procedures (13). Compartment abdominal syndrome is associated to high complication and mortality rates. Failure of aggressive medical and nonoperative treatment is expected to lead to surgery after multidisciplinary evaluation (6, 14, 15). Necrotizing pancreatitis with infected pancreatic necrosis is associated to high mortality rates. If a “Step-up” approach does not solve the pancreatic focus of sepsis by the means of percutaneous drainage among others, this approach may require to be completed by retroperitoneal access to pancreatic necrosis (6, 7). However early open access to the pancreatic necrosis has also been advocated (16). Considering that severe acute pancreatitis represents a challenging disease and may be associated to high mortality and morbidity rates as well as to high costs related to its treatment, it has been suggested to transfer patients to referral centres. The International Association of Pancreatology and the American pancreatic association IAP/APA guidelines recommend transferring patients with severe acute pancreatitis and those who may need interventional radiologic, endoscopic or surgical intervention to a specialist centre. This statement is based on a strong agreement with low quality of evidence. A specialist centre in the management of acute pancreatitis is defined as a highvolume centre with up-to-date intensive care facilities including options for organ replacement therapy, and with daily (i.e. 7 days per week) access to interventional radiology, interventional endoscopy with endoscopic ultrasound and endoscopic retrograde cholangiopancreatography assistance as well as surgical expertise in managing necrotizing pancreatitis. This recommendation is stated on weak agreement with low quality of evidence as there are no studies comparing requirements for specialist centres (6). High-volume hospitals to treat acute pancreatitis have been defined based on a nation-wide American study that supports the idea of more than 118 patients per year (35). Similarly, a more recently nation-wide Japanese study finds better outcomes and length of stay for medium and severe pancreatitis in high-volume hospitals but there is still a lack of accuracy in terms of volume admittance (18). We suggest that implementation of best practice guidelines and multidisciplinary protocols may also be important factors. The aim of this study is to expose the results of treatment of patients with severe acute pancreatitis in a low volume hospital with a multidisciplinary approach and a step-by-step comprehensive chart-flow design.