ORIGINAL ARTICLES

Determinants of Severity in Acute Pancreatitis

A Nation-wide Multicenter Prospective Cohort Study

Sternby, Hanna MD, PhD^∗; Bolado, Federico MD^†; Canaval-Zuleta, Héctor J. MD^‡; Marra-López, Carlos MD^§; Hernando-Alonso, Ana I. MD, PhD^¶; del-Val-Antoñana, Adolfo MD, PhD^||; García-Rayado, Guillermo MD^∗∗; Rivera-Irigoin, Robin MD^††; Grau-García, Francisco J. MD^‡‡; Oms, Lluís MD, PhD^§§; Millastre-Bocos, Judith MD^¶¶; Pascual-Moreno, Isabel MD^||||; Martínez-Ares, David MD, PhD^∗∗∗; Rodríguez-Oballe, Juan A. MD^†††; López-Serrano, Antonio MD, PhD^‡‡‡; Ruiz-Rebollo, María L. MD, PhD^§§§; Viejo-Almanzor, Alejandro MD^¶¶¶; González-de-la-Higuera, Belén MD^†; Orive-Calzada, Aitor MD^§; Gómez-Anta, Ignacio MD^||||||; Pamies-Guilabert, José MD, PhD^∗∗∗∗; Fernández-Gutiérrez-del-Álamo, Fátima MD^††††; Iranzo-González-Cruz, Isabel MD^‡‡‡‡; Pérez-Muñante, Mónica E. MD^§§§§; Esteba, María D. MD^¶¶¶¶; Pardillos-Tomé, Ana MD^¶¶; Zapater, Pedro MD, PhD^||||||||; de-Madaria, Enrique MD, PhD^{∗∗∗∗∗}

Author Information

^∗Department of Surgery, Institution of Clinical Sciences Malmö, Lund University, Malmö, Sweden

^†Department of Gastroenterology, Complejo Universitario de Navarra, Pamplona, Spain

^‡Department of Gastroenterology, Hospital Son LLatzer, Palma de Mallorca, Spain

^§Department of Gastroenterology, Hospital Universitario Araba, Vitoria-Gasteiz, Spain

^¶Department of Gastroenterology, Hospital Gregorio Marañón, Madrid, Spain

^||Department of Gastroenterology, Hospital Universitari i Politècnic la Fe, Valencia, Spain

^∗∗Department of Gastroenterology, University Clinic Hospital, Aragón Health Research Institute (IIS Aragón), Zaragoza, Spain

^††Department of Gastroenterology, Hospital Costa del Sol, Marbella, Spain

^‡‡Department of Gastroenterology, Hospital Arnau de Vilanova, Valencia, Spain

^§§Department of Surgery, Consorci Sanitari de Terrassa, Barcelona, Spain

^¶¶Department of Gastroenterology, Hospital Universitario Miguel Servet, Zaragoza, Spain

^||||Department of Gastroenterology, Hospital Clínico Universitario, Valencia, Spain

^∗∗∗Department of Gastroenterology, Hospital Meixoeiro, Vigo, Spain

^†††Department of Gastroenterology, Hospital Universitario Vírgen Macarena, Seville, Spain

^‡‡‡Department of Gastroenterology, Hospital Universitario Doctor Peset, Valencia, Spain

^§§§Department of Gastroenterology, Hospital Clínico Universitario, Valladolid, Spain

^¶¶¶Department of Gastroenterology, Hospital Puerta del Mar, Cádiz, Spain

^||||||Department of Radiology, Hospital Gregorio Marañón, Madrid, Spain

^∗∗∗∗Department of Radiology, Hospital Universitari i Politècnic la Fe, Valencia, Spain

^††††Department of Radiology, Hospital Costa del Sol, Marbella, Spain

^‡‡‡‡Department of Gastroenterology, Hospital Arnau de Vilanova, Valencia, Spain

^§§§§Department of Surgery, Consorci Sanitari Terrassa, Barcelona, Spain

^¶¶¶¶Department of Radiology, Consorci Sanitari Terrassa, Barcelona, Spain

^||||||||Department of Clinical Pharmacology, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain

^{∗∗∗∗∗}Department of Gastroenterology, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL-FISABIO Foundation), Alicante, Spain.

Reprints: Enrique de-Madaria, MD, PhD, Servicio de Aparato Digestivo, Hospital General Universitario de Alicante. Calle Pintor Baeza 12, Alicante 03010, Spain. E-mail: [email protected].

Participating investigators:

Ana María Argüelles-Arias MD PhD, Federico Argüelles-Arias MD PhD, Fabio Ausania MD PhD, Eduardo Bajador-Andreu MD, Federico Bertoletti MD, Jaume Boadas MD, María P. Bodenlle-Bello MD, Juan I. Cervera MD, Mar Concepción-Martín MD, José L. de-Benito MD, Francia C. Díaz MD, Daniel de-la-Iglesia-García MD, Ángel Ferrández MD, Esther Fort-Martorell MD, Roberto García-Figueiras MD, Cristina Gil-García-Ollauri MD, Miguel González-de-Cabo MD, Silvia Guzmán-Suárez MD, Jennifer Hinojosa-Guadix MD, Ricardo Ituarte-Uriarte MD, Nelly Lareu-Balza MD, María E. Lauret-Braña MD, José Lariño-Noia MD, Patricia Latorre MD, Jesús Leal-Téllez MD, María A. Marcaide MD, Gregorio Martín MD, Emma Martínez-Moneo MD, Pilar Marqués-García MD, María M. Menso MD, Alicia Mesa-Álvarez MD, Oswaldo Moreno MD, Elida Oblitas MD, José A. Pajares-Díaz MD, Carlos Prieto-Martínez MD, Noé Quesada-Vázquez MD, María Rodríguez-Peláez MD, José I. Rodríguez-Prada MD, Beatriz Romero-Mosquera MD, Carmen L. Rosales-Alexander MD, María J. Soria-de-la-Cruz MD, Jordi Soriano MD, Carla Tafur-Sánchez MD, María A. Udaondo-Cascante MD.

This study received no funding.

The authors have no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.annalsofsurgery.com).

Annals of Surgery 270(2):p 348-355, August 2019. | DOI: 10.1097/SLA.0000000000002766

Abstract

Objective:

The aim of this study was to compare and validate the different classifications of severity in acute pancreatitis (AP) and to investigate which characteristics of the disease are associated with worse outcomes.

Summary of Background Data:

AP is a heterogeneous disease, ranging from uneventful cases to patients with considerable morbidity and high mortality rates. Severity classifications based on legitimate determinants of severity are important to correctly describe the course of disease.

Methods:

A prospective multicenter cohort study involving patients with AP from 23 hospitals in Spain. The Atlanta Classification (AC), Revised Atlanta Classification (RAC), and Determinant-based Classification (DBC) were compared. Binary logistic multivariate analysis was performed to investigate independent determinants of severity.

Results:

A total of 1655 patients were included; 70 patients (4.2%) died. RAC and DBC were equally superior to AC for describing the clinical course of AP. Although any kind of organ failure was associated with increased morbidity and mortality, persistent organ failure (POF) was the most significant determinant of severity. All local complications were associated with worse outcomes. Infected pancreatic necrosis correlated with high morbidity, but in the presence of POF, it was not associated to higher mortality when compared with sterile necrotizing pancreatitis. Exacerbation of previous comorbidity was associated with increased morbidity and mortality.

Conclusion:

The RAC and DBC both signify an advance in the description and differentiation of AP patients. Herein, we describe the complications of the disease independently associated to morbidity and mortality. Our findings are valuable not only when designing future studies on AP but also for the improvement of current classifications.

Article Keywords

Keywords
acute pancreatitis, Atlanta classification, determinant-based classification, follow-up study, infection, local complications, morbidity, mortality, necrosis, organ failure, revised Atlanta classification, revision of the Atlanta classification, severity

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Determinants of Severity in Acute Pancreatitis

A Nation-wide Multicenter Prospective Cohort Study