| Background and Objective:Acute pancreatitis is one of the most common acute abdomen in clinical work. It is characterized as high mortality rate, fast progress and serious. Generally speaking, mild acute pancreatitis tends to be self limiting. However, severe acute pancreatitis is such a deadly disease that the mortality rate can be as high as 36%-50%. On the other hand, the morbidity of severe acute pancreatitis is also very high. These characteristics of severe acute pancreatitis make it difficult to be treated in clinic. Recently, along with the development of severe medicine, medical imaging and minimally invasive technology, the mortality of acute pancreatitis decreased dramatically, scholars of world wide have gradually reached a consensus on the treatment strategy. For example, the global consensus on the treatment of acute pancreatitis was reached at the 1992 Atlanta Symposium, and a set of international acute pancreatitis classification system was established. Then in 2012, the international pancreatitis group revised the Atlanta standard, which formed a more perfect version of the 2012 edition of the Atlanta standard. Although we have made these achievements, the mortality rate of severe acute pancreatitis is still around 20%, which indicates that there are still more work to do on pathogenesis and treatment of acute pancreatitis.There was a study on so-called step-up approach suggested that the step-up approach can reduce the incidence of major complications such as organ failure, new raised organ failure and so on. This step-up approach included percutaneous catheter drainage(PCD), minimally invasive retroperitoneal necrotectomy and other minimal approach. In case that drainage can not achieve the effect, the patient may enter the next phase of treatment. In above study, 35% patients’ condition would be improved after PCD treatment, in addition, the rates of complications including organ failure were significantly lower than open necrotectomy. Because of its favorable clinical effect, this step-up approach has become the main strategy in treatment of acute pancreatitis.However, this step-up approach is not perfect, there is still a lot to be improved. In the above study, the step-up approach did not reduce mortality rate compared with open necrotectomy(19% vs. 16%, respectively). In addition, step-up approach did not mention treatment for abdominal or pelvic fluid collection in acute pancreatitis.In fact, abdominal or pelvic fluid collection is one of the most common implications in moderately severe or severe acute pancreatitis, correctly treatment for this complication or not will affect mortality rate in certain degree. Previous studies argued that sterile fluid collection can be spontaneously remission and did not need special treatment. However, there is no evidence supporting this hypothesis. For now, there is no consensus conclusion yet on how to deal with abdominal or pelvic fluid collection.In view of the above problem, we carried out a study on the treatment of abdominal paracentesis drainage(APD) for moderately severe or severe acute pancreatitis. We found that this treatment can prevent new onset organ failure, however, the mechanism of this remission is not clear. In this study, we evaluate the effectiveness and safety of APD, and discuss the possible mechanism of this remission.Methods:1. First, we evaluated the effectiveness of APD by retrospective methods. Moderately severe or severe acute pancreatitis patients in Chengdu Military General Hospital from January 2010 to July 2013 were subdivided into two groups(PCD group and APD+PCD group, 53 vs. 49 patients, repectively). Mortality rate, organ failure and other variables were observed.2. Second, in order to evaluated the safety of APD, we carried out a prospective study(registration number: ChiCTR-OCH-13003427). All eligible patients were randomly divided into two groups(APD group and no APD group) by random number. the main end point was infection. The following variables were observed: the rate of infection, time of infection, infection bacterial spectrum and so on.3. At last, along with the above prospective study, we detected inflammation factors in the two groups such as IL-10, IL-6, IL-1β and TNF-α by ELISA in blood serum and abdominal or pelvic fluid collection within 48 hours from registration and in day 4, day 6, day 8 and day 10 from registration. In blood serum, CRP, miRNA-146 a, miRNA-21 and mi RNA-16 were detected by RT-PCR. We also evaluated disease severity by APACHE II, Marshall, CTSI and so on.Results:1. Retrospective study showed that, there was no significant difference between PCD group and APD+PCD group(10.2% vs. 11.9%, respectively, p=0.102). However, mortality rate due to organ failure was significantly higher in PCD group than that in APD+PCD group(p=0.05). Organ failure was significantly higher in PCD group than in APD+PCD group(87.8% vs. 77.3%, respectively, p=0.037), multi-organ failure was also higher in PCD group than in APD+PCD group(63.3% vs. 35.8%, respectively, p=0.017). Organ failure lasted longer in PCD group than in APD+PCD group(20.7± 3.1 days vs. 15.6±2.2 days, respectively, p=0.022).2. In prospective study, we found that the overall infection complication rate in APD group was significantly lower than in no APD group(38.1% vs. 52.7%, respectively, RR=0.72,95% CI 为 0.55-0.95,p=0.019). The rate of infection necrosis was also lower in APD group than in no APD group(12.7% vs. 23.3%, respectively, RR=0.55,95%CI 为0.31-0.95, p=0.034). However, there was no significant difference in pneumonia, bacteremia and sepsis. The last time of pneumonia, bacteremia and sepsis were comparable in the two groups. Nevertheless, the last time of infection necrosis was shorter in APD group than in no APD group(25.3 ± 4.3 vs. 31.9 ± 5.6, respectively, p=0.031). Infection bacterial spectrum was almost the same in the two groups.3. In APD group, inflammation factors in blood serum and fluid collection such as IL-6 、 IL-1β and TNF-α decreased gradually along with APD treatment. And IL-10 as a protective factor increased for a few days and then drop down. Accordingly, the severity of disease declined day by day. In no APD group, although inflammation factors decreased over time, the speed was slow compared with APD group. Most inflammation factors were higher in no APD group at the same time than in APD group. The severity index was higher in day 4 and day 8 in no APD group than in APD group. Variation tendency in the two groups were different, however, no significant difference was found between the two groups.Conclusions：1. APD treatment added in step-up approach may decrease disease-special mortality rate and organ failure rate. The success of APD treatment depends on the following factors. First, this procedure must be carried out under direction of ultrasound. Second, the details of fluid collection such as the amount and location of fluid collection must be detected carefully before APD procedure.2. Infection complication rate in APD group was lower than that in no APD group. There were no significant differences on diagnosis time infection bacterial spectrum between the two groups, which indicated that APD did not increase infection risk in moderately severe or severe acute pancreatitis. At the same time, APD may prevent infection necrosis but not infection related mortality rate.3. In the early stage of moderately severe or severe acute pancreatitis, the following possible mechanism may explain why APD reduce organ failure and mortality rate. First, APD reduce inflammation factors in blood serum and fluid collection and thus reduce SIRS reaction, so as to achieve the purpose of reduce the damage to organ function and mortality rate. Second, APD may interfere with the process of inflammatory reaction through regulate expression of miRNA, and as a result decrease organ failure and mortality rate. |
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