JPNclinical practice guidelines 2021 with easy‐to‐understand explanations for the management of acute pancreatitis

Abstract

Background In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan. Method In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system. Results Thirty‐six clinical questions (CQ) were prepared in 15 subject areas. Based on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast‐enhanced computed tomography (CT) grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which were shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step‐up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 h of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics are administered in mild pancreatitis. Conclusion All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.

Expanding minimally invasive treatment approaches for refractory large walled‐off necrosis after necrotizing pancreatitis

“…Therefore, a minimally invasive procedure called video‐assisted retroperitoneal debridement (VARD) has been developed for WON, in which necrosectomy is performed via a retroperitoneal approach under laparoscopic assistance. A meta‐analysis of cohort studies reported that morbidity and mortality rates were significantly lower with VARD than with open necrosectomy 7 . However, although various minimally invasive approaches have been developed, there are limited data on the usefulness of these treatments for large WONs (i.e., more than 15 cm).…”

“…Moreover, if a large WON with an extensive amount of necrotic tissue is asymptomatic and sterile, spontaneous resolution without drainage can be expected in some cases. Therefore, prevention of infection starting in the early stages of pancreatitis is important, and the effectiveness of early enteral nutrition is recognized 7 …”

“…Therefore, prevention of infection starting in the early stages of pancreatitis is important, and the effectiveness of early enteral nutrition is recognized. 7 With the development and expansion of various minimally invasive treatment approaches, clinical outcomes in patients with large and complicated WONs have been improving. Development of treatment strategies based on a minimally invasive approach using mainly an endoscopic step-up approach depending on the complexity of WON and prevention of progression to refractory WON are required to further improve clinical outcomes.…”

“…A meta-analysis of cohort studies reported that morbidity and mortality rates were significantly lower with VARD than with open necrosectomy. 7 However, although various minimally invasive approaches have been developed, there are limited data on the usefulness of these treatments for large WONs (i.e., more than 15 cm). Thus, there may be many cases that require highly invasive open necrosectomy, which is ultimately the limit of minimally invasive treatment for large WONs.…”

Management of severe acute pancreatitis: all hands to the pump

“…As shown in several surveys ( 6 , 7 ), poor compliance was reported in terms of nutrition and prophylactic antibiotics. Further attempts are necessary to facilitate easy use of guidelines such as pancreatitis bundles provided in the Japanese clinical practice guidelines ( 8 ).…”