Liver, Pancreas and Biliary TractPredictors of severe and critical acute pancreatitis: A systematic review
Introduction
Prediction of disease severity is one of the most important clinical goals in the management of patients with acute pancreatitis. An accurate marker of severity allows early identification of those patients who require transfer to a referral centre, treatment in an intensive care unit (ICU), and/or specific interventions [1], [2], [3]. The literature is replete with studies investigating predictors for the severity of acute pancreatitis, but these studies are limited by the great variation in their definitions of severity (i.e. what they aim to predict) [4]. Definitions include local and/or systemic complications (as defined by the 1992 Atlanta symposium) [5], infectious pancreatic complications alone, admission to an ICU, length of ICU or hospital stay, complications requiring intervention, grading by radiological imaging [6], and multifactorial prognostic clinico-biochemical scores [7]. It has been argued that improvements in predicting severity of acute pancreatitis can hardly be achieved without agreement on which endpoints should be used [2].
Recent advances in the understanding of the drivers of severity of acute pancreatitis has drawn attention to the importance of persistent organ failure (POF), as well as infected pancreatic and/or peripancreatic necrosis (IPN), as determinants of mortality in patients with acute pancreatitis [8], [9]. As a result, the determinant-based international multidisciplinary classification has been developed [10] and validated [11], [12], [13]. One of the features of the new classification is a new category of acute pancreatitis severity called “critical” acute pancreatitis. This category incorporates patients with both POF and IPN. The new international multidisciplinary classification has also updated the definitions of “severe” acute pancreatitis. This category now incorporates patients with either POF or IPN [10].
Given that POF and/or IPN are the major determinants of mortality in acute pancreatitis, there is an urgent clinical need to determine the best available predictors of these two determinants of severity. To the best of our knowledge, no study has systematically addressed this important clinical question. Thus, the aim of this study is to conduct a systematic literature review to determine the utility of predictors of POF and IPN, both alone and in combination.
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Study identification
A search of EMBASE, Cochrane Reviews, and PubMed databases from 1950 to January 2013 was carried out. The search strategy for predictors of POF included “persistent organ failure/ OR multiple organ failure” AND “acute pancreatitis” AND “Predicting/ OR predictor/ OR predict/ OR identify/ OR indicator/ OR indicate/ predictors/ OR sign”. The search strategy for predictors of IPN included “infected pancreatic necrosis/ OR infective pancreatic necrosis/ OR infected necrotizing pancreatitis/ OR
Predictors of POF
A total of 526 studies were assessed for eligibility and 7 studies examining a total of 15 predictors were included in the final review. The flow chart of the selection process is outlined in Fig. 1 (PRISMA diagram). Of the 15 predictors included, 11 were evaluated in more than 1 study. The methodological quality of the included studies was excellent, as 6 of 7 studies reached the maximum score of 11 points (Table 1).
Table 1 lists the characteristics of the studies examining predictors of POF.
Discussion
This is the first systematic literature review that has focused on predictors of POF and IPN in acute pancreatitis. Although numerous reviews have described various predictors of a “severe” course of acute pancreatitis, there was a remarkable heterogeneity between the studies in terms of what they actually aimed to predict [2], [3]. These endpoints for the prediction of “severe” acute pancreatitis included, among others, death, length of hospitalization, ICU admission, and need for surgery. The
Conflict of interest
None declared.
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