Non-Compliance with National Guidelines in the Management of Acute Pancreatitis in the United Kingdom

Abstract

Background: Deficiencies and lack of standardisation of the management of acute pancreatitis in the UK have been reported. National UK guidelines for the management of acute pancreatitis were published in 1998. However, implementation of national guidelines in other areas has been patchy, suggesting that evaluation of the uptake of the pancreatitis guidelines would be appropriate. Aim: Identification of current practice in the management of acute pancreatitis as reported by consultant surgeons, in order to determine how effectively the UK guidelines have been introduced into practice. Methods: A questionnaire was posted to 1,072 full members of the Association of Surgeons of Great Britain and Ireland. It consisted of 13 questions that aimed to identify the surgeon’s practice in the management of patients with acute pancreatitis in relation to key points in the UK guidelines. We compared the practice of hepatobiliary and pancreatic (HBP) vs. non-HBP specialists, and teaching vs. non-teaching hospital surgeons using the χ² test. Results: Of 538 responses (50%), 519 were from consultant surgeons. 59 did not look after patients with acute pancreatitis and 89 (17%) had a HBP interest. There were differences between the recommendations in the guidelines and reported practice, particularly in the use of critical care resources and referral to specialist units. Of consultants looking after acute pancreatitis 371 (72%) were non-HBP specialists. There were significant overall differences between the practice of HBP specialists and non-specialists: in severity assessment (Glasgow and C-reactive protein vs. Ranson criteria); indication and timing of requesting computed tomography (routinely at 7–10 days vs. when clinically indicated); nutritional support (enteral feeding vs. no support), and in common bile duct assessment prior to cholecystectomy (intra-operative cholangiography vs. endoscopic retrograde cholangiopancreatography). There was no significant difference between practice in teaching and non-teaching hospitals. Conclusion: Implementation of national guidelines for the management of acute pancreatitis was greater in the practice of HBP specialists than non-specialists. This has implications for the rationale of creating guidelines, and for the strategies associated with their introduction.

Recurrent acute biliary pancreatitis: the protective role of cholecystectomy and endoscopic sphincterotomy

“…The coexistence of cholangitis is an accepted indication for the performance of endoscopic retrograde cholangiopancreaticography (ERCP). However, whether this procedure is performed for patients with ABP depends on local expertise and guidelines, as is the decision to perform an endoscopic sphincterotomy (ES) [2][3][4][5].…”

“…After patients have recovered from their first attack of ABP, most guidelines advocate a cholecystectomy to prevent a recurrent attack or other gallstone-related disorders such as symptomatic choledocholithiasis, cholecystitis, gallstone ileus, jaundice, and cholangitis [2][3][4][5]. ''Recurrent'' symptomatic choledocholithiasis after an initial attack of ABP may be preexisting common bile duct (CBD) stones not detected at the time of the primo episode or stones that migrated from the gallbladder into the CBD after initial stone clearance.…”

“…The coexistence of cholangitis is an accepted indication for the performance of endoscopic retrograde cholangiopancreaticography (ERCP). However, whether this procedure is performed for patients with ABP depends on local expertise and guidelines, as is the decision to perform an endoscopic sphincterotomy (ES) [2][3][4][5].After patients have recovered from their first attack of ABP, most guidelines advocate a cholecystectomy to prevent a recurrent attack or other gallstone-related disorders such as symptomatic choledocholithiasis, cholecystitis, gallstone ileus, jaundice, and cholangitis [2][3][4][5]. ''Recurrent'' symptomatic choledocholithiasis after an initial attack of ABP may be preexisting common bile duct (CBD) stones not detected at the time of the primo episode or stones that migrated from the gallbladder into the CBD after initial stone clearance.…”

Evaluation of the Best Power Setting of Laser Waves in Pancreatic Surgery: ECHO ND-YAG Laser Ablation on Bovine Pancreatic Tissue

“…[1][2][3][4][5][6][7][8] Tissue is loose, friable and much vascularized; so, pancreatitis and major bleedings are well-described during surgery. 1 Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis, and mortality rates up to 39% have been reported.…”

“…1 Approximately 20% of patients with acute pancreatitis develop pancreatic necrosis, and mortality rates up to 39% have been reported. [1][2][3][4][5][6][7][8] Surgical debridement (so-called necrosectomy) is the traditional management of necrotizing pancreatitis with specific indications. [1][2][3][4][5][6][7][8][9] In severe AP, current indications for surgery include the presence of infected pancreatic necrosis, extensive sterile necrosis in patients in whom symptoms have failed to resolve despite maximal conservative treatment or in patients who develop catastrophic complications related to pancreatic necrosis such as bleeding, visceral perforation or infarction.…”