Journal Club Prince of Wales of Hospital

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Journal ClubPrince of Wales of Hospital

• 8 March 2004
• Wendell Neilson and Greg Keogh

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The Question

• Pt with severe pancreatitis due to
  hyperlipidaemia
• Admitted to ICU, intubated, inotropic support
• CT scan showed large amount of free
  intraperitoneal fluid
• Significance? Treatment?

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The Search

• Medline search
• Pancreatitis
• Pancreatic fluid
• Aspiration
• Drainage

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The Article

• Acute Pancreatitis Effect of Somatostatin
  Analogs and peritoneal Lavage
• A meta-analysis of peritoneal lavage for acute
  pancreatitis
• Journal of Gastroenterology and Hepatology
• Vol. 16, 2001, 689-693
• Platell, C Cooper, D Hall, J
• Dept of Surgery, University of Western Australia

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Aim

• Study performed a meta-analysis of randomized
  prospective trials looking at peritoneal lavage
  for pancreatitis
• West, 1965, reported the successful use of
  peritoneal lavage for patients with pancreatitis
  (3 pts).

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Method

• Randomized, prospective trials only, appearing in
  peer review journals
• 1966-1999
• Minimum of 20 pts
• Outcome measures of the trials were mortality and
  major complications (necrosis, psuedocysts,
  abscess, sepsis)

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Method

• Peritoneal dialysis catheter either at the
  umbilicus, or lesser sac.
• Lavage via balanced electrolyte solutions
• Each trials control and treatment groups were
  compared, meta-analysis performed via the
  Homogenous Case method

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Results

• 8 trials found on medline, total of 333 pts
• Control groups
• Conservative management 4 trials n224
• Pancreatic resection 2 trials n56
• Drainage of lesser sac 1 trial n24
• Lavage for 2 days 1 trial n21
• Treatment groups
• Lavage via dialysis catheter 1-12 days
• Lavage of lesser sac 4 12 days

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Results

• No significant difference in any of the studies
  when compared for mortality or morbidity of the
  lavage and control groups
• Mortality (total) study vs control
• 43/160 vs 44/173 Odds ratio 0.94
• Morbidity (total) study vs control
• 50/160 vs 56/173 Odds ratio 0.98

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Discussion

• Study found that lavage doesnt improve outcome
  in pancreatitis (supporting the results of the
  individual trials).
• Why no benefit?
• Large volume, unable to localize contaminant
• Lavage may remove inflammatory mediators
• Lavage retards the rate of mesothelial
  regeneration/healing

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Discussion

• 2 trials looked at adding protease inhibitors to
  the lavage solution to improve efficacy
• Both trials showed no difference in M M of the
  trial arms

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Conclusion

• The use of peritoneal lavage in patients with
  pancreatitis in not supported by the literature

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Answer

• Trial suggested that there is no benefit from
  lavaging the peritoneal cavity in pancreatitis.
• Pt subsequently improved on conservative
  treatment, and was eventually discharged

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• Likes
• Defined outcome measures.
• Analyzed trials that were prospective in design,
  from peer review journals
• Dislikes
• Misleading title no mention of somatostatin
  analogs in the trial
• No mention of the severity of the pancreatitis
  for comparison i.e. Ransons scores
• No mention about the assignment of pts to study
  or control groups
• Included a study comparing lavage for 2 days
  (control) vs lavage for 7 days (treatment)

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