Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Acute pancreatitis is a common gastrointestinal disease requiring acute care in the intensive care unit.
Speaker: The range of severity in acute pancreatitis is wide.
Speaker: Patients present with mild cases on one extreme and on the other end of the spectrum, patients can present with severe cases with multiple organ failure and serious local complications require critical care.
Speaker: In today's episode of the podcast, we will focus on current management recommendations for severe acute pancreatitis.
Speaker: Our guest is Dr. Mark Besenling.
Speaker: Dr. Besselink is professor of pancreatic and hepatobiliary surgery at Amsterdam University Medical Centers.
Speaker: Dr. Besselink is a member of the Dutch Pancreatitis Study Group, is the senior investigator of the Pointer Clinical Trial, a randomized clinical trial published recently in the New England Journal of Medicine that evaluated immediate versus postponed interventions for infected necrotizing pancreatitis.
Speaker: Mark, welcome to Critical Matters.
Speaker: Thank you very much, and thanks for having me.
Speaker: It's a great honor.
Speaker: Obviously, we were talking before we started recording that this is a common disease that is full of dogma, especially in the ICU, and old precepts that probably are not aligned with what current evidence is.
Speaker: And I know that you, through your work with the Dutch Pancreatitis, have really advanced our understanding of the surgical management and the interventional management of this disease.
Speaker: So perhaps a good place to start would be just with the basics of how do we diagnose acute pancreatitis?
Speaker: Yeah, so thanks.
Speaker: So basically abdominal pain, amylase or lipase higher than three times the upper limit of normal for your hospital and or CT scan findings compatible with pancreatitis.
Speaker: Now you need only two out of three.
Speaker: So we have a new patient.
Speaker: You can basically only diagnose it with
Speaker: abdominal pain and serum values.
Speaker: You don't necessarily need a scan, but if you want to make a scan, be aware.
Speaker: If you do a scan on admission, you may miss necrotizing pancreatitis and collections, which take a few days to develop.
Speaker: Yeah.
Speaker: And I think it's an important point also in terms of what you require, because we tend to forget that we can make diagnoses such as acute pancreatitis with simple labs and a good clinical
Speaker: history and exam and not necessarily have to get like a thousand things for every patient that we suspect abdominal pain in, right?
Speaker: Correct, correct.
Speaker: The only reason, the only indication basically for a scan on admission for acute pancreatitis, that is if you are unsure about the diagnosis that, for instance, a patient has peritonitis, you should not have peritonitis, meaning abdominal guarding or pain or when releasing the abdominal wall.
Speaker: You should not have that with pancreatitis, which is a retroperitoneal organ.
Speaker: So you should have a lot of pain, but no physical signs of peritonitis.
Speaker: Absolutely.
Speaker: And in terms of etiology for acute pancreatitis, what are the things that you think our clinicians and listeners should be aware of?
Speaker: Yeah, so the vast majority is gallstones.
Speaker: Even if you don't see the gallstones, even in those patients, more than half, it's still gallstones or biliary sludge or biliary cause.
Speaker: And then alcohol, so probably, so biliary nowadays, they're 60%, six zero, alcohol another 20, and then you have another 10 in which we cannot find a cause first.
Speaker: And then the rest is just a long, a long range of causes.
Speaker: In terms of, you mentioned how we make a diagnosis, some of the important causes.
Speaker: I presume that part of our initial workup really focuses obviously in A, making the diagnosis, B, evaluating the etiology,
Speaker: and C, perhaps trying to evaluate how severe the presentation is.
Speaker: But what would you recommend, Mark, as an initial diagnostic workup in terms of the basic things that we should be looking at as clinicians that were suspecting acute pancreatitis?
Speaker: Well, in the older days, there was a lot of emphasis on doing predictive scores, predicting how severe the pancreatitis would be.
Speaker: But in essence, that's no longer relevant because at the moment, A,
Speaker: There is no intervention or treatment that you will start on a basis of high risk and B, there is probably not a single ICU in the world anymore that will admit the patient who may become sick in the future.
Speaker: So I think the early management, basically you as intensivists need to train us as surgeons and internal medicine or gastroenterology doctors how to assess vital functions in the first one and two days, meaning
Speaker: giving sufficient fluids and probably a lot of fluids, but monitor carefully and slow down.
Speaker: We found the amount of fluids administered once there is sufficient urinary output and we see blood pressure and heart rate stabilizing.
Speaker: And those things is what go wrong in many, many places.
Speaker: Patients are not treated with sufficient fluids initially.
Speaker: And then later on, they I mean,
Speaker: Many hospitals, I don't know what it's like in the U.S., but in the Netherlands, you may just get three or four liters of saline infusion for four days in a row without anyone thinking after 20 hours, we need to tune this down a bit.
Speaker: Yeah, absolutely.
Speaker: And we'll definitely dig into that a little bit more.
Speaker: But you did mention severity.
Speaker: And I wanted to ask you your perspective as a clinician.
Speaker: So obviously, there's a lot of risk scores that have been published around pancreatitis, Apache 2, Ransom's criteria, modified Glasgow acute pancreatitis.
Speaker: are those really useful at the bedside or are they more for studies?
Speaker: Pure for studies.
Speaker: So what they are used for in studies is, so you can include the 50% of patients who are high risk, the 5-0, 50%.
Speaker: And among those, half of them will actually get sick.
Speaker: So you have a higher risk ratio in your clinical trials.
Speaker: But basically outside clinical trials, and I hope I don't offend anyone, but basically there's no clinical use for these scores at the present time.
Speaker: And probably as we talk about the definition, ultimately what it really matters is assessing the patient and trying to identify where their local complications and acute organ dysfunction, correct?
Speaker: Yeah.
Speaker: So, so one, uh, simple technique is looking at CRP for instance.
Speaker: So if CRP remains high after three, four days, doesn't come down.
Speaker: The vast majority of these patients have necrotizing pancreatitis, but I expect
Speaker: as an intensivist, you would not see these patients because they are typically on the ward.
Speaker: The most challenging patients are of course the ones who present with organ failure and remain in organ failure throughout the first one.
Speaker: Absolutely.
Speaker: And Mark, let me ask you, in terms of classifications or definitions for a severe acute pancreatitis, I understand that today we kind of go either with the Atlanta classification or what's called the determinant base classification.
Speaker: Could you comment on that a little bit more?
Speaker: Yeah, so the Atlanta, revised Atlanta classification is what I use, but there is a determinant-based classification.
Speaker: They use the same variables, which are collections with necrosis in our around the pancreas and then organ failure.
Speaker: I think in the end, it does not really make that much difference.
Speaker: What you need to be on the lookout for is organ failure and collections in and around the pancreas.
Speaker: So if you have a collection which is non-infected, that does not require treatment.
Speaker: In fact, if you treat that, it will become infected and you will worsen the prognosis.
Speaker: So a lot of it is just straightforward, state-of-the-art organ failure management.
Speaker: So if you have organ failure, clearly it's severe.
Speaker: And the other is if you have a collection
Speaker: but you do not have organ failure, but you also do not have fever or signs of infection, then basically it's still, it is called severe pancreatitis, but the outcome is clearly a lot better than once you have.
Speaker: Yeah.
Speaker: So clearly, like you mentioned, Mark, organ failure should be within the purvey of what we do in the intensive care unit.
Speaker: and there's nothing specific for acute pancreatitis.
Speaker: We support the organs like we do in any other multi-system disease.
Speaker: And then the other part of this is understanding fluid collections and that distinction that we'll dive in a little bit deeper in a little bit of where it's infected or not.
Speaker: But before we go there, what I would like to do is just touch on some of the management issues at the initial phase.
Speaker: We did talk a little bit about fluids, and I just want to kind of cap the fluid discussion with what you said earlier, right?
Speaker: It's kind of either we have an error of omission or of commission.
Speaker: So either we don't give enough fluids or we give too much fluids and both obviously are dangerous for these patients.
Speaker: So really trying to provide the adequate amount of fluids.
Speaker: Is there any comments that you have or any preferences based on the literature and what type of fluid we should be using?
Speaker: No, I mean, you'd be surprised in Europe how many hospitals still give high amounts of regular saline.
Speaker: To these patients, which which I guess, but I mean, intensivists are my view, the specialists on this.
Speaker: But there are two randomized trials from China where they intervened in fluid management and tried to get and based on a metric just did a maximum aggressive resuscitation.
Speaker: And in those studies, mortality was worse by by maximizing aggressive resuscitation.
Speaker: So I guess it's just common sense and basically tailoring it to a urinary output, cardiovascular science.
Speaker: But I mean, that's what you guys and girls are much better than we as non-intensivists.
Speaker: Is there any value?
Speaker: I know there's some studies that suggest that perhaps a ringer's lactate might have some benefits, but that obviously has never been demonstrated in a clinical trial.
Speaker: But is there, I mean, there's other reasons why probably isotonic, um,
Speaker: and fluids are valuable in critical care.
Speaker: Is that something that you think about a lot?
Speaker: Yeah, I do.
Speaker: I do.
Speaker: And I do think it makes more sense.
Speaker: In smaller randomized trials, it seems a bit better, but more on, not on the hard endpoints like mortality.
Speaker: So those studies have not been done, but everybody thinks that, yeah, it would make sense.
Speaker: Probably if you would do a very, very large study, most people would predict that it would really be a benefit, but so far there's not been shown.
Speaker: So in terms of kind of where we stand today, obviously, is appropriate judicial fluid management early on without overdoing it, perhaps some advantages to use ringers lactate as your to-go fluid.
Speaker: And when you talked about higher mortality, one of the concerns, obviously, that we have with acute pancreatitis is intra-abdominal compartment syndrome.
Speaker: Is that something that should always be in the back of our mind and maybe something that we don't think about so much as medical intensivists, but definitely that you and the surgical world see all the time?
Speaker: Absolutely.
Speaker: So, so in my view, those are, I think the two main issues show an intra-abdominal catastrophe that you may miss, which is either abdominal compartment syndrome or bowel ischemia, chronic necrosis, something like that.
Speaker: That's, that's, that's one.
Speaker: And then the other is, um, of course, bleeding, maybe the second and then the third, in fact, the necrosis.
Speaker: And the, the problem comes when you have a patient who has been sick from the beginning,
Speaker: and has a collection and everybody starts towards the source control reflex, which makes sense.
Speaker: But in essence, the first one, two weeks of pancreatitis are like a major trauma, major burn patient.
Speaker: It is inflammation, it's not infection.
Speaker: Excellent.
Speaker: And the second aspect that I think has a lot of misconceptions still is nutritional support in the early phases.
Speaker: So historically, people have talked about strict MPOs.
Speaker: Then people started pushing for post-eugenial tube feeds.
Speaker: There's people, obviously, who have always pushed.
Speaker: And now we learn that parental nutrition is probably not a good idea.
Speaker: What's the summary of what we should be doing for these patients from a nutritional standpoint?
Speaker: Yeah.
Speaker: So actually, in a bigger step, but we did with it, multiple randomized trials showing in anything you want to do in pancreatitis more aggressive or earlier or sooner or bigger, it's always worse.
Speaker: So the same is for the nutrition.
Speaker: You can hold off safely for a couple of days if a patient is still on a ventilator or not on a ventilator, but not able to get sufficient calories, then you can start naso enteral tube feeding or probably the ICU setting, nasogastric feeding.
Speaker: You don't need to feed aggressively in the first couple of days.
Speaker: It's basically like a post-op patient.
Speaker: They need some nutrition, but there's no clinical benefit from an aggressive nutritional management within 24 hours.
Speaker: That was the Python trial that was published in the New England Journal of Medicine.
Speaker: And in terms of if you start enteral feeding in somebody who, let's say, is intubated, and is there any value in having a post-piloric tube?
Speaker: or should you just do an orogastric and that's okay?
Speaker: Yeah, so there are three, I think there are three relatively small randomized trials, also in the ward, the clinical ward setting.
Speaker: There's no downside to nasogastric feeding.
Speaker: So if you are used in the ICU to do nasogastric feeding, you can do that in these pancreatitis patients as well safely.
Speaker: So the summary here would be if somebody's not intubated, maybe even outside of the ICU,
Speaker: start enteral, I mean, regular nutrition or once they tolerate it based on their symptoms without necessarily going to be too aggressive and starting something immediately.
Speaker: And then those who are a little bit sicker, once they're hemodynamically compensated and stable, start some sort of enteral nutrition and see how they tolerate.
Speaker: Yeah, well, that, yeah, exactly.
Speaker: So you mentioned, yeah, hemodynamically stable patient.
Speaker: That is an odd thing that happened in our probiotics trial where we did, we intervened
Speaker: Within the first 72 hours of pangotitis of nasal enteral probiotics combined with fiber rich tube feeding, those patients had a significant worse mortality, mostly used to probably, although we are not sure, probably a non-inclusive mesenteric ischemia, a thing that intensivists recognize from, say, post-op patients getting bowel ischemia from the from the exact spot
Speaker: where tube feeding enters the bowel.
Speaker: And that is a poorly understood phenomenon, but it's probably related to flow.
Speaker: So that's actually another argument to withhold exactly as you summarized tube feeding in the first couple of days.
Speaker: Excellent.
Speaker: Another area that I think we've always been back and forth and still unclear for a lot of clinicians is antibiotics.
Speaker: So from giving everybody antibiotics to getting a CT in everybody and you see anything that you suspected necrosis giving antibiotics to probably a more current evidence aligned recommendation of not giving antibiotics in the early days.
Speaker: Could you just tell us, Mark, your take on antibiotics?
Speaker: Yeah.
Speaker: So it's become quite clear from several randomized trials that the hypothesis that if you sterilize
Speaker: the guts or just give systemic antibiotics improves outcome.
Speaker: That's not true.
Speaker: So prophylactic antibiotics, no role for in pancreatitis.
Speaker: The one thing that is that has become very clear from the point of trial last month in New England, that once you have documented or highly suspicion, high suspicion of infected necrotizing pancreatitis, then one in three or more than one in three of the patients will be treated successfully with only antibiotics.
Speaker: But that is a treatment
Speaker: not a prophylaxis.
Speaker: So really we should remember that in the early phases these patients might present with systemic inflammatory response syndrome similar to sepsis, but it's likely not due to infection, so there's no rush to give them infections.
Speaker: And we should only give them antibiotics early on if we have a documented infection, either cholangitis, we can sometimes present with pancreatitis or some other infection.
Speaker: And then, like you said, once we have a documented or high suspicion
Speaker: or a fluid collection that is necrotic and infected, obviously antibiotics not only are treatment, but they can avoid, as we'll talk a little bit, more interventions down the road.
Speaker: I think that's important because I still see that a lot of people, as a knee-jerk reflection, will basically start antibiotics in very sick pancreatitis patients in the ICU on day one.
Speaker: Yeah, and moreover, so if you're treating a very, very sick patient,
Speaker: and you see fluid in the abdomen.
Speaker: The reflex we have as intensivists, probably also in surgeons, the urge to drain that is very strong.
Speaker: I mean, for many years, I had sort of an on-page, I was on call with my pager for including patients in these trials we did.
Speaker: And I spoke to so many intensivists, it's really difficult to withhold intervention.
Speaker: And I feel your pain, but please hold off.
Speaker: The action bias, right?
Speaker: We always want to do more.
Speaker: And we're learning that sometimes more is worse.
Speaker: Absolutely.
Speaker: Exactly.
Speaker: And especially in pancreatitis, which I think is a one off disease.
Speaker: It doesn't compare.
Speaker: It's very, it is challenging.
Speaker: It's the only disease that I know that you just hold off antibiotics, wait, wait, wait.
Speaker: And that's really, it doesn't feel natural to us.
Speaker: Yeah.
Speaker: What about the role of ERCP?
Speaker: Same story.
Speaker: Do less, less is more.
Speaker: So,
Speaker: We did APEC, APEC randomized trial published in Lancet.
Speaker: Again, aggressive within 24 hours.
Speaker: ERCP, everyone with biliary pancreatitis predicted high risk.
Speaker: So the high risk score versus just wait and see.
Speaker: And again, no benefit for early ERCP, maybe even a bit worse.
Speaker: So again, also there, just wait.
Speaker: Look at the cholestasis parameters.
Speaker: Clearly, if bilirubin or whatever goes up,
Speaker: and you get gallingitis, 39 degree higher fever and spiking chills and a bilirubin of 100.
Speaker: Of course, then you need to do an ERCP, but actually that's super rare.
Speaker: So in the vast majority of patients, the stones will just pass, claustasis lab will improve and you do not need an ERCP, one.
Speaker: And two, if in doubt, most big centers nowadays will have availability of EOS, endoscopic ultrasound, to check first what's going on inside the bowel, because don't forget mortality of ERCP is 0.5.
Speaker: to 0.5% mortality.
Speaker: Yeah, so definitely, I mean, I think, like you said, in terms of our approach, more conservative.
Speaker: And would cholangitis be a situation where you actually would give not only antibiotics but also do an ERCP earlier?
Speaker: Absolutely, yeah.
Speaker: That's an indication for an urgent ERCP, yes.
Speaker: Okay, perfect.
Speaker: And then I wanted to dive into, obviously we did mention the POINTER trial, but ultimately the management of local complications.
Speaker: Could we start, Marc, just by a very brief overview of what are the types of local complications that we talk about in acute pancreatitis?
Speaker: Yeah, so we have two things.
Speaker: So you have necrosis of the parenchyma or the fatty tissue around the pancreas.
Speaker: So necrotizing pancreatitis is a term which summarizes
Speaker: any form of necrosis in and around the pancreas.
Speaker: That's one then, too.
Speaker: You have an acute necrotic collection, meaning like basically anything around the bankers that sort of starts to to wall off to look like a little bit of world off thing.
Speaker: And once it's fully walled off, you have a wall fully encircling it, then you call it walled off necrosis and the letter, the walled off necrosis, the one
Speaker: is what most gastroenterologists would like to see because that clearly, then there's a clear demarcation between dead and alive stuff, which makes any intervention a lot safer.
Speaker: And obviously the main factor to get there is time.
Speaker: Absolutely.
Speaker: And another aspect that I believe is important, and you mentioned it earlier, is that it is not uncommon to have just edema or some fluid around the pancreas and acute pancreatitis.
Speaker: And I think a lot of clinicians might confuse that with these more complicated and necrotizing collections.
Speaker: And like you said, have that impulse to think that a needle should be stuck there.
Speaker: Can you talk about that a little bit?
Speaker: Yeah, so basically the size of the collection doesn't so much matter.
Speaker: It can be five by 10 or 30 by 30.
Speaker: If the patient has no clinical signs of infection,
Speaker: then that can be left alone.
Speaker: You'd be surprised what you see in a scan six months later.
Speaker: So either if there are infected gas bubbles within the collection, so these little black dots and you see them typically spread out through the collection, which will tell you, listen, this is not a fluid collection.
Speaker: This is thick stuff, necrosis, because the gas is infected inside it.
Speaker: Otherwise you would see an air fluid level, right?
Speaker: That's one.
Speaker: And two, if you're in doubt,
Speaker: patient is very sick.
Speaker: Half of the patients, only half of those who have infection in the collection have gas bubbles.
Speaker: The other half you cannot see on the CT scan.
Speaker: So those may require a sterile aspiration to detect any bacteria in the collection.
Speaker: So that's the key point if they're infected or not.
Speaker: If not infected, leave it alone.
Speaker: It's not the source of your patient being sick.
Speaker: Excellent.
Speaker: And just to
Speaker: To dive a little bit deeper on this, I think it's important that there are a lot of clinical signs that can give you a good indication of potential infection of these necrotic fluid collections.
Speaker: You mentioned the CT appearance.
Speaker: I presume that also you could get biomarkers such as procalcitonin, and if that is very low, it'd be very unlikely that it's an infection, right?
Speaker: You can also look at other markers as well.
Speaker: And that in a lot of cases, like you said,
Speaker: The clinical diagnosis can be made and we can avoid a needle insertion to document infection.
Speaker: But in some cases, if you're not sure, you might have to put that needle in, right?
Speaker: Yeah.
Speaker: So I think in the first two weeks of pancreatitis in a sick patient, the ICU patient is basically impossible to differentiate between inflammation and infection.
Speaker: So luckily, that's also not the major issue because it's very rare to have infection of a collection in the first two weeks.
Speaker: And if it were so, it can still be treated only with antibiotics.
Speaker: So I think in the first two weeks, there's definitely no no point to stick in anything there around the pancreas.
Speaker: After two weeks, then that may help you.
Speaker: Maybe it'll help you to tailor antibiotic treatment, although strangely enough.
Speaker: because it's impacted because it's necrosis is not an abscess.
Speaker: It's not a fluid collection.
Speaker: So you may have one bacteria on the left side of the collection.
Speaker: You can have another bacteria on the right side of the collection.
Speaker: So it's not 100% guaranteed that if you culture something into tailor your antibiotics to that, that the patient will improve.
Speaker: So that makes it a bit more complicated.
Speaker: But if you're three, four weeks out and in doubt, I would stick a needle in with a nice sterile approach.
Speaker: We would do the fire intervention radiology
Speaker: that may then really help you.
Speaker: Excellent.
Speaker: And in terms of managing this, obviously, as a surgeon, you mentioned that your first impulse is always to perform surgery.
Speaker: But in pancreatitis, it's a very individualized case where perhaps waiting and not intervening is the best mode.
Speaker: And we've learned that through the years.
Speaker: But I also think that we went from surgery to delaying surgery to stage interventions.
Speaker: And now
Speaker: We have the POINTER trial that you published recently in the New England Journal of Medicine.
Speaker: Could you just tell us a little bit about that trial, what you were looking at and what you found?
Speaker: Yeah, basically for the fourth or the fifth time in a row, I lost count.
Speaker: The same thing.
Speaker: We tried to be better by being more aggressive.
Speaker: So we thought, okay, let's do as we do in pancreatic surgery, which is any infected fluid drain as soon as possible, no matter how small aggressive drainage showed.
Speaker: We randomized patients who had documented or highly suspicion of infection to percutaneous or endoscopic transgastric drainage within 24 hours.
Speaker: So very aggressive versus antibiotics.
Speaker: Wait and wait and see if we can reach the stage of walled off necrosis and then drain.
Speaker: And surprisingly, contrary to what we were expecting, later delaying waiting was better.
Speaker: These patients, the ones who recovered, actually were home two weeks earlier.
Speaker: two weeks earlier, which was a big surprise.
Speaker: Yeah.
Speaker: And also they required, from what I read, far less interventions, which is always a good thing for patients from the patient perspective, because every intervention is associated with its own potential complications, like you mentioned.
Speaker: And the other thing that also struck me as very, very interesting was that a lot of these patients actually did not require intervention at all, that there was a percent that was not insignificant, that with conservative management got better.
Speaker: Absolutely, 39%, only antibiotic treatment, no drain needed, 39%.
Speaker: So I think that's another lesson of less is more and really being very thoughtful about these patients and trying to manage those impulses.
Speaker: Another question as we wrap up the complication, the local complication management is, are there other indications other than surgery that might require, I'm sorry, other than infection that might require intervention?
Speaker: I know that's not very common, but a lot of times these can cause obstructions and other problems.
Speaker: Yeah, absolutely.
Speaker: No, so you need to be on the lookout for abdominal compartment syndrome.
Speaker: So any patient that you have progressive difficulty ventilating or needs to go on his abdomen to be ventilated, you need to get a bladder pressure.
Speaker: So if you have new, and it's a standard definition, if you have new progressing organ failure and the bladder pressure goes up above 21,
Speaker: Think of it is basically abdominal compartment syndrome and that that requires a full length midline laparotomy and then with temporary closure of the oven with some system that may save the patient.
Speaker: There are some specialists I know who say abdominal compartment syndrome is just an early sign of death.
Speaker: But in fact, I think to about one in three, maybe even up to one in two of the patients can be saved.
Speaker: with adequate early management of abdominal compartment syndrome, one and two, clearly bleeding, which may occur after as quickly as a week already, one to three weeks out, especially with infection that may need usually intervention or radiology to coil the bleeding and then third, bowel ischemia.
Speaker: Excellent.
Speaker: And are there any concerns, I mean, in terms of obstruction of biliary ducts?
Speaker: Is that something that can occur with these collections?
Speaker: I have definitely not seen a lot of it, but obviously th is is your area of expertise.
Speaker: Yeah, there's a lot of talk of it.
Speaker: There may be some mild color stasis, but it's very, very, very rare that the collection fully obstructs the extrahepatic bile duct.
Speaker: So that's not a clinical scenario you should worry about.
Speaker: Perfect.
Speaker: And one further question from a surgical perspective, which is not something that really we deal with in the ICU, but it's very important for our patients.
Speaker: And they usually ask us about this.
Speaker: You mentioned that the vast majority or the most important etiology relates to gallstones.
Speaker: And what's the timing of gallbladder removal and surgery for these patients?
Speaker: Yeah, so that was actually one of the trials that we did at a positive result with the proactive intervention.
Speaker: is that if it's a mild pancreatitis, it should not be a patient that you get in the ICU, a mild patient, so no organ failure, no collection.
Speaker: That patient should not go home with the gallbladder.
Speaker: So that patient should have a gollocystectomy during the same admission.
Speaker: The only thing that the current idea is that if you have a severe pancreatitis, then the gallbladder needs to be removed after six weeks after discharge.
Speaker: But that may change in the future.
Speaker: So we are planning a study on that topic actually as well.
Speaker: But so mild pancreatitis, same admission called cystectomy, non-mild pancreatitis, outpatient clinic of the surgeon first.
Speaker: As we close the clinical conversation, Mark, you obviously have done an amazing job with the Dutch pancreatic group pancreatitis group in terms of all the studies that you have really applied a rigorous scientific approach.
Speaker: And like you said, that's why we do the studies because a lot of times you're,
Speaker: clinical intuitions are proven wrong and you've demonstrated, right, that a lot of times perhaps a more moderate approach is better for patients.
Speaker: What are the next big questions that you think remain unanswered in acute pancreatitis?
Speaker: So the holy grail in pancreatitis is how to sort of put a cap, how to damp the initial pro-inflammatory response because we just looked at 10-year
Speaker: uh, ICU mortality in early pancreatitis.
Speaker: And we've improved very, very little in the early pancreatitis mortality, a bit, but really surprisingly little.
Speaker: So, so we, that's, that's the next big thing.
Speaker: We need to find a way to, to, to make sure that pro-inflammatory peak is, is less high.
Speaker: And, and, and, and so, so studies are coming, but, but that's, that's the next big thing.
Speaker: Excellent.
Speaker: Well, I really want to be respectful of your time and appreciate you sharing your expertise.
Speaker: Again, thanks for the wonderful trial that was recently published, and we'll include all these trials in the show notes.
Speaker: Mark, we usually close the podcast with some questions unrelated to the clinical topic.
Speaker: Would that be okay?
Speaker: Absolutely.
Speaker: Are there any books that have influenced you significantly or that you have gifted to others?
Speaker: House of God.
Speaker: So that's a, it's interesting because obviously when, when I went to training, that was a, a perfect read.
Speaker: I think that newer generations probably a bit detached from that, but a lot of it still holds true.
Speaker: So we'll definitely put that in the, in the, in the, in the show, in the show notes.
Speaker: The second question relates to something that you believe to be true in medicine or in life that most other people don't believe or don't act like they believe.
Speaker: Yeah.
Speaker: So,
Speaker: So randomized trials, so they are a pain and a nuisance and they cost years to complete.
Speaker: But if you find a group of friends and you can pull it off, you save more patients potentially with one trial than treating patients as a doctor during your entire career.
Speaker: And I think this is a very timely comment.
Speaker: One of the reasons why I was so excited to talk with you and read your paper is that it was not related to COVID.
Speaker: And we've been kind of immersed in COVID for almost two years in the ICUs, and we're just coming off our fourth wave here in Texas.
Speaker: But I think that we see that still in COVID that even in a pandemic, getting together and doing the trials is what moves us forward.
Speaker: And there's no reason why we shouldn't be doing that in 2021 and finding a way to collaborate and find the right answers.
Speaker: Because over and over again, when we do the studies, we find surprises.
Speaker: And a lot of what we think makes sense does not pan out.
Speaker: But also, I think that there's no, like you said, one trial, despite the pain and the difficulty, ultimately will have an impact for years to come on patients that is hard to measure.
Speaker: Absolutely.
Speaker: And the last question is just, is there anything that you would want to share with our audience?
Speaker: Something that you want every intensivist to know could be a quote or fact or just a comment.
Speaker: Well, it's often if you treat these sick patients, you may get into like a sort of a discussion with the surgeon.
Speaker: And I've had this feeling recently.
Speaker: often.
Speaker: But what I think what we should do more is say to the surgeon, well, please, find five minutes, come here, let's sit down, two of us, look at the scan and discuss this case.
Speaker: Because I think the typical phone call of the intensivist to the surgeon, you need to come over and do an operation or the other way around is usually what isn't the best way to treat our patients.
Speaker: And I make these mistakes still every day myself.
Speaker: But I think just get down here.
Speaker: So let's sit down together.
Speaker: I'll come to you.
Speaker: I don't care.
Speaker: But just
Speaker: look at the patient, sit down to get a look at the scan and come up with a plan.
Speaker: That is, that is something we should do more than we probably all of us do.
Speaker: I think it's a great point, Mark.
Speaker: And I guess in terms of summary, the summarize of that is what I always try to remind myself, like you said, because we all fall in those same traps is we should listen more and ask more questions.
Speaker: Agree.
Speaker: Excellent.
Speaker: Well, thank you so much for your time and I really appreciate it.
Speaker: We'll definitely, uh,
Speaker: include all the trials you mentioned in the show notes.
Speaker: And I hope you have a wonderful rest of the day.
Speaker: Thank you so much, Mark.
Speaker: Thank you very much.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
