Modern Management of Benign and Malignant Pancreatic Disease, An Issue of Gastroenterology Clinics , livre ebook

Gastroenterology Clinics of North America , Vol. 41, No. 1, March 2012
ISSN: 0889-8553
doi: 10.1016/S0889-8553(12)00023-4

Contributors
Gastroenterology Clinics of North America
Modern Management of Benign and Malignant Pancreatic Disease
Dr., Jacques Van Dam, MD, PhD
Keck School of Medicine, University of Southern California, 1510 San Pablo Street, HealthCare Consultation I; Suite 322R, Los Angeles, CA 90033, USA
ISSN  0889-8553
Volume 41 • Number 1 • March 2012

Contents
Cover
Contributors
Forthcoming Issues
Modern Management of Pancreatic Disease
Modern Management of Acute Pancreatitis
Diagnosis and Management of Autoimmune Pancreatitis
The Role of Endoscopic Retrograde Cholangiopancreatography in Patients with Pancreatic Disease
Endoscopic Management of Pancreatic Pseudocysts
Modern Treatment of Patients with Chronic Pancreatitis
The Minimally Invasive Approach to Surgical Management of Pancreatic Diseases
Pancreatic Cystic Neoplasms: Diagnosis and Management
Management of Pancreatic Neuroendocrine Tumors
Pancreas Transplantation
Pancreatic Cancer Screening
Pancreatic Cancer: Radiologic Imaging
The Role of Endoscopic Ultrasonography in the Diagnosis and Management of Pancreatic Cancer
Pancreatic Cancer: Medical Management (Novel Chemotherapeutics)
The Surgical Management of Pancreatic Cancer
Modern Radiation Therapy Techniques for Pancreatic Cancer
Endoscopic Palliation of Pancreatic Cancer
Index
Gastroenterology Clinics of North America , Vol. 41, No. 1, March 2012
ISSN: 0889-8553
doi: 10.1016/S0889-8553(12)00025-8

Forthcoming Issues
Gastroenterology Clinics of North America , Vol. 41, No. 1, March 2012
ISSN: 0889-8553
doi: 10.1016/j.gtc.2012.01.017

Preface
Modern Management of Pancreatic Disease

Jacques Van Dam, MD, PhD,
Keck School of Medicine, University of Southern California, 1510 San Pablo Street, HealthCare Consultation I; Suite 322R, Los Angeles, CA 90033, USA


Jacques Van Dam, MD, PhD, Guest Editor
An issue devoted to the modern management of pancreatic disease? Really ? Is there a cure for pancreatic cancer? Well… no. Have we found a cure for acute pancreatitis? Well…. Can we now prevent post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis? Can we definitively diagnose one particular type of cystic neoplasm of the pancreas from among the wide variety of potential etiologies? Well… no. So what could possibly be so new that a monograph on managing pancreatic disease could deign to use the term “modern” in its title? Read on….
Researchers who study benign and malignant pancreatic disease have not hit the homeruns noted above (international readers will please forgive my American baseball analogy in this paragraph). Nonetheless, there are other ways to score major advances against diseases of this particularly enigmatic organ. The following monograph details the base hits and even the doubles and triples that have led to major advances in recent years.
The pancreas is unique. It serves both exocrine and endocrine functions. Its anatomy and location deep within the body allow benign and malignant changes to go unrecognized by its host, often until late in the course of a disease. And yet, the pancreas is so fragile that endoscopists can sometimes create havoc by simply working in its vicinity.
After reading this monograph, clinicians will learn the most prognostic scoring systems for acute pancreatitis, review the basics for early management of the disease, and see how current practice guidelines have evolved. Advances in radiological imaging when applied to the pancreas have resulted in enhanced staging and improved selection for surgical intervention. Endoscopy of the pancreas via both ERCP and endoscopic ultrasound has led to unprecedented access and potential for nonoperative intervention. Surgical advances have provided the most significant breakthroughs. Pancreatic surgery now takes advantage of both minimally invasive (laparoscopic) approaches and techniques learned from organ transplantation. And noteworthy advances in medical and radiation oncology are extending life expectancy for patients with the most advanced malignant disease while limiting treatment toxicity.
I am indebted to the multidisciplinary team of authors, luminaries in their respective fields, who have graciously given their time and considerable expertise to this monograph. They represent gastroenterologists, endoscopists, radiologists, surgeons, oncologists, and radiation oncologists who have advanced the field and together have created a well-written, well-documented, and well-referenced manual for treating patients with benign and malignant diseases of the pancreas. I also wish to thank Kerry Holland for the opportunity to organize and edit this monograph and Lesley Simon for her outstanding editorial skills. Their support and guidance were essential to its success.
Gastroenterology Clinics of North America , Vol. 41, No. 1, March 2012
ISSN: 0889-8553
doi: 10.1016/j.gtc.2011.12.013

Modern Management of Acute Pancreatitis

Neeraj Anand, MD, Jung H. Park, MD, Bechien U. Wu, MD, MPH *
Department of Gastroeneterology, Kaiser Permanente Los Angeles Medical Center, 1526 North Edgemont Avenue, Los Angeles, CA 90027, USA
* Corresponding author
E-mail address: Bechien.u.wu@kp.org

Keywords
• Acute pancreatitis • BISAP • Mortality • Management • Complications • Fluid Resuscitation • Necrosis

Burden of Acute Pancreatitis in the Modern Era
Recent national survey data indicate a rising incidence of acute pancreatitis in the United States, attributed primarily to a rise in biliary pancreatitis. At present, there are more than 300,000 admissions for acute pancreatitis on an annual basis 1 at a direct cost exceeding $2 billion. 2 Although acute pancreatitis is typically a self-limited illness, up to 15% of patients experience a severe life-threatening form of disease. 3 Length of stay and direct costs vary considerably by severity of disease. In this age of cost containment, modern management of acute pancreatitis has evolved to emphasize effective interventions for prevention and management of complications, as well as appropriate resource utilization. This article addresses recent developments in the management of acute pancreatitis starting from initial hospital presentation extending through discharge and includes discussion of approaches secondary prevention.

Initial Assessment of Severity
Since the Ranson criteria were originally published in 1974, 4 numerous clinical prognostic scoring systems have been developed, the most prominent of which is the APACHE II score. 5 Although it is a widely validated instrument and clearly useful for research purposes, the APACHE II score has failed to gain widespread application in clinical practice as a result of its complexity. A simplified scoring system known as the Bedside Index of Severity in Acute Pancreatitis (BISAP) was developed based on data from 177 U.S hospitals and more than 17,000 cases of acute pancreatitis 6 ( Table 1 ). This five-factor scoring system contains elements that are routinely available at the time of hospital admission and its use during the initial 24 hours of hospitalization has now been validated in several prospective cohort studies. 7, 8 Two specific elements of the BISAP score warrant further discussion. First, blood urea nitrogen (BUN) has received renewed interest as an early prognostic marker in acute pancreatitis. Either an elevated BUN at admission or early rise in BUN was found to be a strong risk factor for mortality in several retrospective and prospective cohort studies of acute pancreatitis. 9, 10 Another component of the BISAP, the systemic inflammatory response syndrome (SIRS), has also been evaluated as a potential risk factor for severe acute pancreatitis ( Table 2 ). Several prospective cohort studies of acute pancreatitis have shown that persistent SIRS, 11 lasting 48 hours or more, is associated with increased risk of necrosis, multiorgan failure, and death ( Fig. 1 ). 12, 13
Table 1 BISAP score and its associated mortality Parameters Value If Present, Points Allocated Serum BUN >25 1 Mental status Impaired 1 SIRS Present 1 Age of the patient >60 years 1 Pleural effusion Present 1   Total Score Mortality (%)   0 0.20   1 0.60   2 2   3 5–8   4 13–19   5 22–27
Table 2 SIRS criteria, defined by the presence of two or more Parameters Value Temperature <36°C or >38°C Heart rate >90 per minute Respiratory rate >20 per minute or Pa CO 2 <32 mm H g White blood cell count <4000 cells/mm 3 or >12,000 cells/mm 3 or 10% bands

Fig. 1 Association of SIRS with Severe Acute Pancreatitis. Pers OF = persistant organ failure; Necrosis = pancreatic Necrosis; ICU = ICU admission; Mortality = Death.

Early Fluid Resuscitation
Vigorous fluid resuscitation is a cornerstone of therapy during the early management of acute pancreatitis. However, recommendations on fluid resuscitation have been based primarily on expert opinion and data from animal models. 14 One retrospective study suggested that timing of fluid resuscitation may be more important than the total volume of fluid administered; in this study, patients receiving a greater proportion of their total fluid resuscitation during the initial 24 hours had reduced complications. 15 However, there are potential hazards associated with vigorous fluid resuscitation, such as pulmonary sequestration, as suggested