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http://dx.doi.org/doi:10.1016/j.dld.2015.03.022
YDLD 2860
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Accepted date:
2-2-2015
17-3-2015
24-3-2015
Please cite this article as: Pezzilli R, Consensus Guidelines on severe acute pancreatitis,
Digestive and Liver Disease (2015), http://dx.doi.org/10.1016/j.dld.2015.03.022
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Review Article
Consensus Guidelines on severe acute pancreatitis
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Authored by: The Italian Association for the Study of the Pancreas (AISP)
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Conflict of interest:
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Correspondence:
interest.
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ABSTRACT
This Position Paper contains clinically oriented Guidelines by the Italian
Association for the Study of the Pancreas (AISP) for the diagnosis and
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1.
INTRODUCTION
In 2010, the Italian Association for the Study of the Pancreas (AISP) released
practical guidelines for acute pancreatitis (AP) [1] and decided that periodical
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revised the guidelines, and the Governing Board decided the process should
be limited to evaluation of the recent literature on the severe forms of AP,
2.
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METHODOLOGY
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The literature search was carried out on the PubMed database by an expert
librarian in June 2014, taking into account the MESH terms and the search
period (the last 10 years). After the first draft, consensus was reached for
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each statement according to the Delphi procedure [6], and both the evidence
level and the recommendation grade were reported according to the Oxford
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criteria [7].
The Consensus Conference was held in Bologna on September 18, 2014; the
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members of the Governing Board as well as the members of the three panels
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S2, in addition to the members of the panels, there were also 32 voters
(representatives of general practitioners, 19 gastroenterologists, 6 surgeons,
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and one non-voting participant representing the patients. Thus, the total
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For the purpose of these Guidelines, severe AP was defined as the presence
of persistent or progressive organ failure and/or local pancreatic
complications [8]. This is an a posteriori definition in which criteria are
applied after the patient has recovered or has died from AP; the purpose was
to ensure the studies on AP were comparable.
New severity categories for AP have recently been suggested [4,5], one
introduces the class of moderate AP (characterised by transient organ failure,
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infected pancreatic necrosis and persistent organ failure) [5]. These classes
are also a posteriori classes. However, from a clinical point of view, reliable
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criteria are needed as soon as possible to predict the course of the disease.
Thus, for predicting the severity of AP, careful clinical assessment, and the
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use of a multiple factor scoring system and imaging studies are suggested.
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CONSENSUS STATEMENTS
3.1
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3.1.1 What are the minimum hospital prerequisites to care for patients with
severe AP?
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year [13].
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3.1.3 What is the best imaging study for diagnosing the presence and extent
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cavity, the term pseudocyst should not be used and the term walled-off
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3.1.5 What is the best imaging study for diagnosing the presence and extent
of a post-AP pseudocyst?
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best imaging studies for diagnosing the presence and the extent of a
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post-AP pseudocyst.
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pancreas alone, in both the pancreas and the peripancreatic tissue or,
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Comment: In the first two or three weeks after the onset of the disease,
pancreatic necrosis is characterised by the absence of a defined wall. On
of pancreatic necrosis?
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effects [23].
3.1.8 What is the definition of walled-off necrosis (WoN)?
Statement: Walled-off necrosis is a mature, encapsulated collection of
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pancreatic and/or peripancreatic necrosis which has developed a welldefined inflammatory wall; it occurs more than four weeks after the
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3.1.9 What is the best imaging study for diagnosing the presence and extent
of WoN?
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between the ductal pancreatic systems, and other spaces or organs due
to the leakage of pancreatic secretions from damaged pancreatic ducts.
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3.1.12 What is the best imaging study for diagnosing a pancreatic fistula
complicating AP?
Statement: Magnetic resonance cholangio-pancreatography (MRCP) is
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3.1.13 Which vascular complications can occur during the course of severe
AP?
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Comment: The splenic vein is the most commonly affected vessel because of
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its extensive contact with the pancreatic gland. Left-sided portal hypertension
and oesophago-gastric varices may subsequently develop with the risk of
bleeding [35]. The most commonly involved arteries are the gastroduodenal
artery and the splenic artery, and their branches. Arterial bleeding can occur
in WoN, a pseudocyst, the gastrointestinal tract or the peritoneal cavity,
usually leading to acute haemorrhagic shock [36-40].
3.1.14 Which is the best imaging study for diagnosing vascular
complications?
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treatment [40,44,45].
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Comment: The diagnosis of ACS requires a high index of suspicion in highrisk patients. It is suggested by increased abdominal girth, associated with
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pressure using a bladder catheter [46]. The latter is the most common
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3.1.17 What is the definition of cholangitis during the course of severe AP?
Statement: Acute cholangitis is a morbid condition with acute
inflammation and bacterial or non-bacterial infection of the bile duct,
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be present.
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3.2
Conservative treatment
3.2.1 What is the role of fluid resuscitation in patients with severe AP?
Statement: Early fluid resuscitation plays a critical role as it aims to
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fluids [58,59].
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requirements should be evaluated every 8-12 hours during the first 24-48
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drugs in the setting of AP. The need for these drugs might be considered on
a case-to-case basis if specific indications, such as peptic disease or
bleeding.
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mortality risk. The results were more heterogeneous for the risk of
complications, but no clear benefit was reported [71]. However, as the
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mainly in the very early phases of severe AP, their efficacy might have been
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[76].
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Comment: There have been contrasting results in the clinical trials conducted
in the past 30 years regarding the role of antibiotic prophylaxis in severe AP.
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Findings of the most recent meta-analyses of RCTs do not support a role for
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trend toward efficacy, yet without significance. This class of antibiotics should
be considered as a first line empiric treatment for patients with suspected
infected pancreatic necrosis. Extra-pancreatic infections (cholangitis, sepsis,
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AP?
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Comment: There are no high quality studies supporting the routine use of
antifungal agents in patients with severe AP [79].
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[82] was the use of probiotics associated with increased mortality due to nonocclusive mesenteric ischemia [83]. Whether this negative effect was due to
the dose or the specific mixture of strains, or to the enteral route of
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the enteral route is not available or not tolerated, and intravenous hydration
should be decreased gradually after admission as the enteral feeding infusion
rate is progressively brought to the target.
3.2.11 When should EN be started in patients with severe AP?
Statement: EN should be started within 24-48 hours from admission,
after obtaining haemodynamic control.
Evidence level 1a, Recommendation grade A
Comment: Retrospective cohort studies, RCTs and a meta-analysis have
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suggested that EN started within 24-48 hours after admission is superior not
only to parenteral nutrition but also to EN started after 48 hours as it is
associated with reduced complications [87-90]. In a retrospective study, early
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EN is also associated with lower mortality [91]. This cut-off time point is
also recommended by the American Society for Parenteral and Enteral
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3.2.12 What is the optimal route for administering EN in patients with severe
AP?
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Comment: Both elemental and polymeric diets are well tolerated in patients
with pancreatitis, and they are equally recommended [99-104]. Enteral
feeding with immune-enhancing ingredients (arginine, glutamine, nucleotides,
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and omega-3 fatty acids) which modulate the host inflammatory and immune
response have recently attracted great interest but, at the moment, there are
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very few published trials and the results are too discordant to make any
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3.2.14 What are the indications for parenteral nutrition in patients with severe
AP?
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outcome.
Evidence level 2b, Recommendation grade B
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renal failure. Monitoring urea excretion may be helpful in tailoring the actual
nitrogen need [105,106].
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3.2.16 What is the optimal timing for restarting oral feeding in patients with
AP?
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single randomised study has shown that early, low volume, oral feeding might
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(early group) or to an oral diet initiated 72 hours after presentation (ondemand group), with tube feeding provided if the oral diet was not tolerated in
208 patients with predicted severe acute pancreatitis. Notably, in the on-
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demand group, 72 patients (69%) tolerated an oral diet and did not require
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tube feeding. This study showed a similar rate of infections and death, and
their composite, in patients receiving early nasoenteric tube feeding, as
compared with an oral diet after 72 hours. This recent study suggests that an
oral diet might be proposed early to patients with severe AP, as two thirds of
them would tolerate it, without a worse outcome [115]
3.2.17 Is evaluation of exocrine pancreatic function recommended after
recovery from severe AP?
Statement: The evaluation of the exocrine pancreatic function is
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and for a longer period of time, such as those who underwent necrosectomy
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months.
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3.3
Interventional treatment
3.3.1 What are the indications for invasive treatment of a fluid collection?
Statement: The indications for the invasive treatment of a fluid
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these results justify invasive treatment only when complications occur [124127].
3.3.2 If treatment of a fluid collection is needed, which is the best timing and
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3.3.3 What are the indications for invasive treatment of pancreatic necrosis?
Statement: Invasive treatment of pancreatic necrosis (infected or not
infected) is indicated after the failure of adequate medical management,
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pancreatitis). The less common indications for intervention are gastric outlet
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[4,131,132,137,138,140,141,144,147,148,153,154].
The management of asymptomatic patients is still unclear [136]. To date,
there are no studies regarding the outcome of treated asymptomatic WoN.
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pseudocysts?
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3.3.7 What are the indications for the invasive treatment of post-AP
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lumen [177-181].
technique of choice?
the collection; access should be chosen via the most direct route,
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[132,137,140,144-149].
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interventional strategy?
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stent positioning. Some patients are not eligible for the above-mentioned
treatments, mainly due to the technical limitations of endoscopic retrograde
cholangio-pancreatography (ERCP), related to duodenal and pancreatic duct
stricture or post-surgical anatomy [34,184]. Endoscopic transmural drainage
has become the procedure of choice for complete duct disruptions which
result in a pseudocyst formation and fistulae. Treatment of a disrupted duct
without peripancreatic collections necessitates bridging of the pancreatic leak
with transpapillary stents or diverting the pancreatic duct flow [34,184].
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prosthesis between the collection and the gastric lumen. The prosthesis
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3.3.14 What are the indications for the invasive treatment of vascular
complications?
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3.3.16 What are the indications for the invasive treatment of ACS associated
with AP?
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abdomen and its negative effects of evisceration of the intestines, fluid losses
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3.3.18 What are the indications and optimal timing for ERCP in severe AP?
Statement: Urgent ERCP should be performed within 24 hours in
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data are present in the setting of severe AP. There are also no data regarding
the role of pancreatic sphincterotomy and/or pancreatic stent placement as a
4.
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CONCLUSIONS
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represent the answer to this need; they are tailored to the new terminology
and definitions proposed by the revised Atlanta classifications [4,5] and
provide several statements for specific clinical questions, evaluating
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in accordance with the current knowledge of the disease; they too are to be
considered a dynamic process, and we expect to update them in the near
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Cancer Institute, Aviano, for her invaluable support in the literature search.
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References
1
http://www.g-i-n.net/document-store/working-groups-
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documents/adaptation/adapte-resource-toolkit-guideline-adaptation-2-
us
cr
0.pdf/view
an
2013;27:727-43.
te
Ac
ce
p
Page 39 of 69
40
ip
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cr
us
10
an
11
te
Ac
ce
p
13
14
Page 40 of 69
41
16
ip
t
17
cr
us
an
18
Miller FH, Keppke AL, Dalal K, et al. MRI of pancreatitis and its
te
19
Ac
ce
p
20
21
22
Page 41 of 69
42
24
cr
ip
t
us
26
an
2012;262:751-64.
27
te
Ac
ce
p
29
30
Page 42 of 69
43
32
ip
t
cr
us
33
an
34
Ac
ce
p
35
te
36
37
Mortel KJ, Mergo PJ, Taylor HM,et al. Splenic and perisplenic
involvement in acute pancreatitis: determination of prevalence and
Page 43 of 69
44
ip
t
cr
39
us
40
an
2011;146:647-52.
te
41
2006;17:1279-85.
Ac
ce
p
Radiology 2010;83:104-12.
42
43
Page 44 of 69
45
44
ip
t
45
46
cr
us
an
47
te
Ac
ce
p
2013 155:910-8.
48
Holodinsky JK, Roberts DJ, Ball CG, et al. Risk factors for intraabdominal hypertension and abdominal compartment syndrome
among adult intensive care unit patients: a systematic review and
meta-analysis. Crit Care 2013;17:R249.
49
50
Page 45 of 69
46
ip
t
cr
52
an
53
us
54
te
55
Ac
ce
p
57
58
Warndorf MG, Kurtzman JT, Bartel MJ, et al. Early fluid resuscitation
reduces morbidity among patients with acute pancreatitis. Clin
Page 46 of 69
47
Gardner TB, Vege SS, Chari ST, et al. Faster rate of initial fluid
resuscitation in severe acute pancreatitis diminishes in-hospital
60
ip
t
us
61
cr
an
62
63
Wu BU, Bakker OJ, Papachristou GI, et al. Blood urea nitrogen in the
Ac
ce
p
64
te
65
66
Page 47 of 69
48
67
ip
t
68
69
cr
1986;100:500-4.
Yoo JH, Kwon CI, Yoo KH, et al. Effect of proton pump inhibitor in
an
70
us
71
2012;60:362-7.
Ac
ce
p
2014;14:102.
te
72
73
74
Page 48 of 69
49
ip
t
cr
76
an
77
us
2013;60:1504-8
78
Ac
ce
p
79
te
Gastroenterol 2011;46:261-70.
80
Hooijmans CR, de Vries RB, Rovers MM, et al. The effects of probiotic
supplementation on experimental acute pancreatitis: a systematic
review and meta-analysis. PLoS One 2012;7:e48811.
81
Page 49 of 69
50
83
ip
t
us
84
cr
85
an
Rev 2010:CD002837.
86
te
Ac
ce
p
88
89
Sun JK, Li WQ, Ke Lu, et al. Early enteral nutrition prevents intra-
Page 50 of 69
51
ip
t
90
91
cr
Gastroenterol 2013;19:917-22.
Wereszczynska-Siemiatkowska U, Swidnicka-Siergiejko A,
us
an
92
Guidelines for the use of parenteral and enteral nutrition in adult and
te
93
Ac
ce
p
94
95
Page 51 of 69
52
2006;40:431-4.
96
ip
t
cr
97
an
98
us
99
te
100
Ac
ce
p
101
Elia M, Engfer MB, Green CJ, et al. Systematic review and metaanalysis: the clinical and physiological effects of fibre-containing
enteral formulae. Aliment Pharmacol Ther 2008; 27:120-45.
102
Page 52 of 69
53
104
ip
t
cr
an
105
us
106
Sitzmann JV, Steinborn PA, Zinner MJ, et al. Total parenteral nutrition
te
107
2012;36:284-91.
Ac
ce
p
108
Shaw JH, Wolfe RR. Glucose, fatty acid, and urea kinetics in patients
with severe pancreatitis. The response to substrate infusion and total
parenteral nutrition. Ann Surg 1986;204:665-72.
109
110
Page 53 of 69
54
blind, placebo controlled trial of intravenous antioxidant (nacetylcysteine, selenium, vitamin C) therapy in severe acute
pancreatitis. Gut 2007;56:1439-44.
Moraes JM1, Felga GE, Chebli LA, et al. A full solid diet as the initial
ip
t
111
cr
us
112
an
of clear liquids versus low-fat solid diet as the initial meal in mild acute
pancreatitis. Clin Gastroenterol Hepatol 2007;5:946-51.
Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA
113
te
114
Ac
ce
p
115
Bakker OJ, van Brunschot S, van Santvoort HC, et al. Early versus ondemand nasoenteric tube feeding in acute pancreatitis. N Engl J Med
2014;371:1983-93.
116
Page 54 of 69
55
Pancreatology 2003;3:303-8.
117
118
ip
t
2012;41:922-7.
Uomo G , Pezzilli R, Gabbrielli A, et al. Diagnostic assessment and
cr
us
119
an
120
te
121
Gastroenterol 2013;19:8065-70.
Ac
ce
p
122
Gupta R, Wig JD, Bhasin DK, et al. Severe acute pancreatitis: the life
after. J Gastrointest Surg 2009;13:1328-36.
123
Das SL, Singh PP, Phillips AR, et al. Newly diagnosed diabetes
mellitus after acute pancreatitis: a systematic review andmetaanalysis. Gut 2014;63:818-31.
124
Cui ML, Kim KH, Kim HG, et al. Incidence, risk factors and clinical
Page 55 of 69
56
126
ip
t
cr
an
127
us
2011; 15:2080-8.
128
te
129
Ac
ce
p
130
131
Page 56 of 69
57
Van Santvoort HC, Bakker OJ, Bollen TL, et al. A conservative and
cr
133
ip
t
an
134
us
Gastroenterol 2003;98:98-103.
135
te
136
Ac
ce
p
137
138
139
Page 57 of 69
58
ip
t
cr
141
an
142
us
1998;228:676-84.
Surg 2010;145:817-25.
143
te
Ac
ce
p
1997;173:71-5.
144
145
146
Page 58 of 69
59
ip
t
147
cr
us
148
Endosc 2011;25:3724-30.
Van Baal MC, Van Santvoort HC, Bollen TL, et al. Systematic review
149
an
te
150
Ac
ce
p
151
152
Page 59 of 69
60
153
154
ip
t
cr
155
Ang TL, Kwek AB, Tan SS, et al. Direct endoscopic necrosectomy: a
an
156
us
157
te
Ac
ce
p
158
159
Page 60 of 69
61
2012;22:e319-21.
160
Itoi T, Nageshwar Reddy D, Yasuda I. New fully-covered selfexpandable metal stent for endoscopic ultrasonography-guided
ip
t
cr
161
us
162
an
2009;69:1085-94.
gateway technique for EUS-guided drainage of symptomatic walledoff pancreatic necrosis. Gastrointest Endosc 2011;74:74-80.
Bahr MH, Davis BR, Vitale GC. Endoscopic management of acute
163
Ac
ce
p
164
te
165
166
167
Page 61 of 69
62
ip
t
cr
169
us
170
an
Endosc 2012;76:586-93.
171
te
Ac
ce
p
173
174
Page 62 of 69
63
ip
t
176
177
cr
2013;45:827-32.
us
178
an
179
Ac
ce
p
180
te
181
182
Page 63 of 69
64
ip
t
184
cr
2010;71:652-4.
us
an
185
te
186
Ac
ce
p
187
188
Page 64 of 69
65
196: 280-4.
189
ip
t
190
191
cr
us
192
an
2007;193:166-70.
Surg 2005;190:489-95.
193
te
Ac
ce
p
195
Page 65 of 69
66
196
ip
t
197
198
cr
Surgery 2005;137:323-8.
us
199
an
Gastroenterol 2008;14:3541-8.
200
Ac
ce
p
201
te
202
Al-Bahrani AZ, Abid GH, Holt A, et al. Clinical relevance of intraabdominal hypertension in patients with severe acute pancreatitis.
Pancreas 2008;36:39-43.
203
Page 66 of 69
67
ip
t
cr
205
206
an
us
te
207
2011;23:367-74.
Ac
ce
p
208
209
210
Page 67 of 69
68
ip
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cr
us
212
213
an
214
te
Ac
ce
p
216
217
Page 68 of 69
69
ip
t
219
cr
an
220
us
Ac
ce
p
te
Gastroenterol 2013;108:1400-15.
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