THE ACCEPTANCE OF CHANGES IN THE MANAGEMENT OF PATIENTS WITH ACUTE PANCREATITIS AFTER THE REVISED ATLANTA CLASSIFICATION

Aceitação das mudanças no manejo dos pacientes com pancreatite aguda após a revisão da Classificação de Atlanta

José Roberto ALVES Gustavo Heitich FERRAZZA Ivan Nazareno NUNES JUNIOR Marcelo Bianchini TEIVE About the authors

ABSTRACT

BACKGROUND:

New recommendations for the management of patients with acute pancreatitis were set after the Atlanta Classification was revised in 2012.

OBJECTIVE:

The aim of the present systematic review is to assess whether these recommendations have already been accepted and implemented in daily medical practices.

METHODS:

A systematic literature review was carried out in studies conducted with humans and published in English and Portuguese language from 10/25/2012 to 11/30/2018. The search was conducted in databases such as PubMed/Medline, Cochrane and SciELO, based on the following descriptors/Boolean operator: “Acute pancreatitis” AND “Atlanta”. Only Randomized Clinical Trials comprising some recommendations released after the revised Atlanta Classification in 2012 were included in the study.

RESULTS:

Eighty-nine studies were selected and considered valid after inclusion, exclusion and qualitative evaluation criteria application. These studies were stratified as to whether, or not, they applied the recommendations suggested after the Atlanta Classification revision. Based on the results, 68.5% of the studies applied the recommendations, with emphasis on the application of severity classification (mild, moderately severe, severe); 16.4% of them were North-American and 14.7% were Chinese. The remaining 31.5% just focused on comparing or validating the severity classification.

CONCLUSION:

Few studies have disclosed any form of acceptance or practice of these recommendations, despite the US and Chinese efforts. The lack of incorporation of these recommendations didn’t enable harnessing the benefits of their application in the clinical practice (particularly the improvement of the communication among health professionals and directly association with the worst prognoses); thus, it is necessary mobilizing the international medical community in order to change this scenario.

HEADINGS:
Pancreatitis; Classification; Severity of illness index; Prognosis

RESUMO

CONTEXTO:

Após a revisão da Classificação de Atlanta, em 2012, foram estabelecidas novas recomendações no manejo dos pacientes com pancreatite aguda.

OBJETIVO:

Objetiva-se avaliar o grau de aceitação e implementação dessas recomendações na prática clínica.

MÉTODOS:

Foi realizada revisão sistemática da literatura com auxílio das bases: PubMed/Medline, Cochrane e SciELO, por meio de busca de estudos em humanos, publicados em inglês e português, no período de 25/10/2012 até 30/11/2018, utilizando os descritores e operador booleano: “Acute pancreatitis” E “Atlanta”. Foram incluídos apenas estudos do tipo Ensaios Clínicos Randomizados que avaliaram alguma recomendação relacionada a revisão da Classificação de Atlanta após 2012.

RESULTADOS:

Foram selecionados 89 estudos após aplicação dos critérios de inclusão, exclusão e avaliação qualitativa. Esses foram estratificados quanto à aplicação ou não das recomendações propostas após a revisão da Classificação de Atlanta. Verificou-se que 68,5% dos estudos aplicaram essas recomendações, principalmente, na classificação da gravidade dos pacientes (leve, moderadamente grave, grave). Desses 16,4% eram estudos de origem norte-americana e 14,7% chineses. Os outros 31,5% limitaram-se a comparar ou apenas validar essa classificação de gravidade.

CONCLUSÃO:

Poucos estudos divulgaram alguma forma de implementação das novas recomendações, apesar dos esforços norte-americanos e chineses. A falta da aparente incorporação dessas recomendações na prática clínica, não permitiu o aproveitamento de suas vantagens (principalmente a melhora da comunicação entre os profissionais e estabelecimento da classificação e identificação precoce dos pacientes mais graves), sendo necessário toda a comunidade médica internacional se mobilizar de alguma forma para mudar esse cenário.

DESCRITORES:
Pancreatite; Classificação; Índice de gravidade de doença; Prognóstico

INTRODUCTION

Pancreatitis consists in the inflammatory process affecting the pancreatic tissue and adjacent areas; the disease can present acute or chronic evolution and records significant incidence in its acute form (from 13 to 45 patients per 100,000 inhabitants per year, previously demonstrated from a nationwide survey in Japan)11. Forsmark Chris E, Timothy B. Gardner, eds. Prediction and management of severe acute pancreatitis. Springer New York, 2015.,22. Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology. 2013;144:1252-61.. Its diagnosis is based on the identification of at least two of the following symptoms: pain in the upper abdomen; amylase and/or lipase values higher than three times the normal reference values; evidence of inflammation in the pancreatic and/or peripancreatic tissue based on complementary imaging examination33. Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol. 2013;108:1400-15..

Propositions focused on changing the concepts and treatment of acute pancreatitis, mainly on the best way to determine the severity of patients, from the beginning of symptoms (abdominal pain), emerged after the publication of the Revised Atlanta Classification on 10/25/201244. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11.. Currently, based on the new recommendations, systemic or local signs of inflammation, the presence or absence of temporary or persistent organ failure (determined based on the modified Marshall classification), and the incidence of local complications (i.e., the incidence of acute liquid collections and of sterile or infected necrosis) are criteria adopted to determine the severity of patients with acute pancreatitis33. Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol. 2013;108:1400-15.

4. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11.
-55. Yang CJ, Chen J, Phillips ARJ, Windsor JA, Petrov MS. Predictors of severe and critical acute pancreatitis: A systematic review. Dig Liver Dis. 2014;46:446-51.. Thus, patients with acute pancreatitis were classified as MILD (absence of organ failure and local or systemic complications), MODERATELY SEVERE (absence of organ failure or, when it happens, it is transient - i.e., it disappears within 48 hours - and can be associated, or not, with local or systemic complications), SEVERE (persistent organ failure - i.e., it remains for more than 48 hours and, when associated with infected pancreatic necrosis, features the most severe conditions, which are associated with the highest mortality rates)22. Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology. 2013;144:1252-61.

3. Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol. 2013;108:1400-15.

4. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11.
-55. Yang CJ, Chen J, Phillips ARJ, Windsor JA, Petrov MS. Predictors of severe and critical acute pancreatitis: A systematic review. Dig Liver Dis. 2014;46:446-51..

Another recent attempt to enhance the severity classification of the patients with acute pancreatitis was the Determinant-Based Classification (DBC). This classification was also developed by several experts worldwide and published simultaneously a the revised Atlanta Classification by the end of 2012, consolidating that the presence of local determinants (sterile or infected pancreatic and/or peripancreatic necrosis) and systemic determinants (transient or persistent organ failure) would be the most appropriated criteria to classify the patients into four categories: mild, moderate, severe and critic, related to their severity55. Yang CJ, Chen J, Phillips ARJ, Windsor JA, Petrov MS. Predictors of severe and critical acute pancreatitis: A systematic review. Dig Liver Dis. 2014;46:446-51.,66. Guo Q, Li M, Chen Y, Hu W. Pancreatology Determinant-based classification and revision of the Atlanta classification, which one should we choose to categorize acute pancreatitis? Pancreatology. 2015;1-6.

7. Chen Y, Ke L, Tong Z, Li W, Li J. Association between severity and the determinant-based classification, Atlanta 2012 and Atlanta 1992, in acute pancreatitis: a clinical retrospective study. Medicine (Baltimore). 2015;94(13):e638.

8. Kadiyala V, Suleiman SL, McNabb-Baltar J, Wu BU, Banks PA, Singh VK. The Atlanta Classification, Revised Atlanta Classification, and Determinant-Based Classification of Acute Pancreatitis: Which Is Best at Stratifying Outcomes? Pancreas. 2016;45:510‐5.

9. Bansal SS, Hodson J, Sutcliffe RS, Sutcliffe RS, Marudanayagam R, Muiesan P, et al. Performance of the revised Atlanta and determinant-based classifications for severity in acute pancreatitis. Br J Surg. 2016;103:427‐33.

10. Dellinger EP, Forsmark CE, Layer P, Layer P, Levy P, Maravi-Poma E, et al. Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg. 2012;256:875‐80.
-1111. Fernandes SR, Carvalho J, Santos P, Moura CM, Antunes T, Velosa J. Atlanta, revised Atlanta, and Determinant-based classification--application in a cohort of Portuguese patients with acute pancreatitis. Eur J Gastroenterol Hepatol. 2016;28:20‐4.. However, the DBC was more minded to the establishment of the severity classification, meanwhile, the revised Atlanta Classification of 2012 presents wider recommendations related to the clinical management of the patients with acute pancreatitis66. Guo Q, Li M, Chen Y, Hu W. Pancreatology Determinant-based classification and revision of the Atlanta classification, which one should we choose to categorize acute pancreatitis? Pancreatology. 2015;1-6.

7. Chen Y, Ke L, Tong Z, Li W, Li J. Association between severity and the determinant-based classification, Atlanta 2012 and Atlanta 1992, in acute pancreatitis: a clinical retrospective study. Medicine (Baltimore). 2015;94(13):e638.

8. Kadiyala V, Suleiman SL, McNabb-Baltar J, Wu BU, Banks PA, Singh VK. The Atlanta Classification, Revised Atlanta Classification, and Determinant-Based Classification of Acute Pancreatitis: Which Is Best at Stratifying Outcomes? Pancreas. 2016;45:510‐5.

9. Bansal SS, Hodson J, Sutcliffe RS, Sutcliffe RS, Marudanayagam R, Muiesan P, et al. Performance of the revised Atlanta and determinant-based classifications for severity in acute pancreatitis. Br J Surg. 2016;103:427‐33.

10. Dellinger EP, Forsmark CE, Layer P, Layer P, Levy P, Maravi-Poma E, et al. Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg. 2012;256:875‐80.
-1111. Fernandes SR, Carvalho J, Santos P, Moura CM, Antunes T, Velosa J. Atlanta, revised Atlanta, and Determinant-based classification--application in a cohort of Portuguese patients with acute pancreatitis. Eur J Gastroenterol Hepatol. 2016;28:20‐4..

Thus, the use of multifactor scoring methods such as Ranson, APACHE II, Glasgow, SAPS II, among others, to determine the severity of patients with acute pancreatitis is no longer recommended1212. Mounzer R, Langmead CJ, Wu BU, Evans AC, Bishehsari F, Muddana V, et al. Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis. Gastroenterology. 2012;142:1476-82.,1313. Ferreira Ade F, Bartelega JA, Urbano HC, de Souza IK. Acute pancreatitis gravity predictive factors: which and when to use them? ABCD, Arq Bras Cir Dig. 2015;28:207-11.. The delay in establishing patients’ severity level is one of the main disadvantages associated with the use of scoring methods such as the Ranson criteria (the most used system in past clinical practices), which requires 48 hours to determine the severity of acute pancreatitis1414. Amálio SMRA, Macedo MATV, Carvalho SMMA, Moreno RP. Avaliação da mortalidade na pancreatite aguda grave: estudo comparativo entre índices de gravidade específicos e gerais. Rev Bras Ter Intensiva. 2012;24:246-51.. Moreover, this 48-hour period is not based on the onset of the clinical picture, but on the hospitalization date, when the first complementary serum exams are performed1414. Amálio SMRA, Macedo MATV, Carvalho SMMA, Moreno RP. Avaliação da mortalidade na pancreatite aguda grave: estudo comparativo entre índices de gravidade específicos e gerais. Rev Bras Ter Intensiva. 2012;24:246-51.. Although APACHE II (another among the most used criteria) can be calculated in the first 24 hospitalization hours, it was originally developed to be applied in Intensive Care Units and requires the analysis of 12 parameters in order to estimate a possible organ failure. Therefore, this complex method comprises many criteria that are not directly correlated to the prognosis of patients with pancreatitis1515. Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008;57:1698‐703..

In addition, other possible serum markers have been evaluated to help improving the implementation of criteria capable of determining the severity of patients with acute pancreatitis, based on laboratory tests such as hematocrit, urea, C-reactive protein and other inflammatory cytokines1616. Deng LH, Hu C, Cai WH, Chen WW, Zhang XX, Shi N, et al. Plasma cytokines can help to identify the development of severe acute pancreatitis on admission. Medicine (Baltimore). 2017;96:e7312.. Some prognostic risk factors focused on predicting the most severe forms of acute pancreatitis have also been investigated. So far, only overweight (body mass index >25 kg/m2) and hyperglycemia (blood glucose level higher than 11.1 mmol/L or 200 mg/dL) have been identified and established as eligible factors1313. Ferreira Ade F, Bartelega JA, Urbano HC, de Souza IK. Acute pancreatitis gravity predictive factors: which and when to use them? ABCD, Arq Bras Cir Dig. 2015;28:207-11.,1717. Jin Z, Xu L, Wang X, Yang D. Risk Factors for Worsening of Acute Pancreatitis in Patients Admitted with Mild Acute Pancreatitis. Med Sci Monit. 2017;23:1026-32..

The best detailing of local complications such as acute peripancreatic collections, sterile or infected pancreatic and peripancreatic necrosis, pseudocysts, and sterile or infected delimited pancreatic necrosis stands out among concepts that changed after the Atlanta Classification revision44. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11.,1818. Souza GD, Souza LRQ, Cuenca RM, Jerônimo BSM, Souza GM, Vilela VM. Artigo de Revisão Entendendo o Consenso Internacional Para as Pancreatites Agudas: classificação de Atlanta 2012. Arq Bras Cir Dig. 2016;29:206-10.,1919. Baker ME, Nelson RC, Rosen MP, Blake MA, Cash BD, Hindman NM, et al. ACR Appropriateness Criteria® acute pancreatitis. Ultrasound Q. 2014;30:267‐73.. Acute peripancreatic collections can develop near the pancreas in the early stage of the disease (often within 48 hours after clinical picture onset) and do not present internal solid component44. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11.,1818. Souza GD, Souza LRQ, Cuenca RM, Jerônimo BSM, Souza GM, Vilela VM. Artigo de Revisão Entendendo o Consenso Internacional Para as Pancreatites Agudas: classificação de Atlanta 2012. Arq Bras Cir Dig. 2016;29:206-10.,1919. Baker ME, Nelson RC, Rosen MP, Blake MA, Cash BD, Hindman NM, et al. ACR Appropriateness Criteria® acute pancreatitis. Ultrasound Q. 2014;30:267‐73.. Pseudocysts are amylase-rich liquid collections (without solid components) whose external area simulates a pseudocapsule in the pancreatic and/or peripancreatic region; they emerge after four weeks of disease evolution44. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11.,1818. Souza GD, Souza LRQ, Cuenca RM, Jerônimo BSM, Souza GM, Vilela VM. Artigo de Revisão Entendendo o Consenso Internacional Para as Pancreatites Agudas: classificação de Atlanta 2012. Arq Bras Cir Dig. 2016;29:206-10.,1919. Baker ME, Nelson RC, Rosen MP, Blake MA, Cash BD, Hindman NM, et al. ACR Appropriateness Criteria® acute pancreatitis. Ultrasound Q. 2014;30:267‐73.. On the other hand, acute necrotic collections are liquid collections associated with necrotic tissues in the pancreas and/or in the peripancreatic region; in most cases, they can maintain communication with the pancreatic duct or with its branches44. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11.. Delimited pancreatic necrosis is a necrotic collection found within a fibrotic capsule; it often becomes fibrotic 4 weeks after the onset of acute necrotizing pancreatitis44. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11.,1818. Souza GD, Souza LRQ, Cuenca RM, Jerônimo BSM, Souza GM, Vilela VM. Artigo de Revisão Entendendo o Consenso Internacional Para as Pancreatites Agudas: classificação de Atlanta 2012. Arq Bras Cir Dig. 2016;29:206-10.

19. Baker ME, Nelson RC, Rosen MP, Blake MA, Cash BD, Hindman NM, et al. ACR Appropriateness Criteria® acute pancreatitis. Ultrasound Q. 2014;30:267‐73.
-2020. Ashley SW, Perez A, Pierce EA, Brooks DC, Moore FD, Whang EE, Banks PA, Zinner MJ. Necrotizing pancreatitis: Contemporary Analysis of 99 Consecutive Cases. Ann Surg. 2001;234:572-9..

Finally, based on the best scientific evidences, the application of the new concepts and recommendations published after the revision of the Atlanta Classification in the clinical practice has several advantages and benefits such as: 1. Improving the therapeutic conduct and dialogue among different health professionals involved in the management of patients with acute pancreatitis through the establishment of new criteria, as well as of more uniform and precise terminologies, to diagnose and identify, mainly, the forms of local complications2121. Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;6736:1-12.

22. Cunha EFC, Rocha MS, Pereira FP, Blasbalg R, Baroni RH. Necrose pancreática delimitada e outros conceitos atuais na avaliação radiológica da pancreatite aguda. Radiol Bras. 2014;47:165-75.

23. Sheu Y, Furlan A, Almusa O, Papachristou G, Bae KT. The revised Atlanta classification for acute pancreatitis: a CT imaging guide for radiologists. Emerg Radiol. 2012;19:237-43.
-2424. Ribeiro G, Silva G, Martins M, Bogea E, Cantanhede J, Abreu J. Etiologia E Mortalidade Por Pancreatite Aguda: Uma Revisão Sistemática. Arquivos Catarinenses de Medicina. 2017;46:168-81.; 2. Improving the severity stratification of patients with acute pancreatitis, based on the importance given to the incidence of organ failure in the classification of (mild, moderately severe and severe) acute pancreatitis44. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11.,2121. Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;6736:1-12.; 3. Facilitating and improving the management and monitoring of the therapeutic success of patients with acute pancreatitis through the inclusion of new imaging criteria to classify the tomographic findings in the evaluation of these patients2222. Cunha EFC, Rocha MS, Pereira FP, Blasbalg R, Baroni RH. Necrose pancreática delimitada e outros conceitos atuais na avaliação radiológica da pancreatite aguda. Radiol Bras. 2014;47:165-75.; 4. Helping the medical community to plan clinical studies based on standardized parameters, which will have impacts on the recommendations for the establishment of future interventions and specific treatments for patients with acute pancreatitis1818. Souza GD, Souza LRQ, Cuenca RM, Jerônimo BSM, Souza GM, Vilela VM. Artigo de Revisão Entendendo o Consenso Internacional Para as Pancreatites Agudas: classificação de Atlanta 2012. Arq Bras Cir Dig. 2016;29:206-10.,2121. Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;6736:1-12.,2424. Ribeiro G, Silva G, Martins M, Bogea E, Cantanhede J, Abreu J. Etiologia E Mortalidade Por Pancreatite Aguda: Uma Revisão Sistemática. Arquivos Catarinenses de Medicina. 2017;46:168-81.; 5. Identifying the role played by infected necrosis as determinant factor of high mortality rates associated with the prognosis of acute pancreatitis2121. Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;6736:1-12.,2222. Cunha EFC, Rocha MS, Pereira FP, Blasbalg R, Baroni RH. Necrose pancreática delimitada e outros conceitos atuais na avaliação radiológica da pancreatite aguda. Radiol Bras. 2014;47:165-75..

Unfortunately, despite the advantages and benefits mentioned above, it seems that the world has not fully adhered to the new recommendations issued after the Revised Atlanta Classification for acute pancreatitis44. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11.. Thus, the aims of the current systematic review were to evaluate this scenario and to investigate whether these recommendations have already been accepted and implemented in current medical practices2424. Ribeiro G, Silva G, Martins M, Bogea E, Cantanhede J, Abreu J. Etiologia E Mortalidade Por Pancreatite Aguda: Uma Revisão Sistemática. Arquivos Catarinenses de Medicina. 2017;46:168-81.,2525. Tércio DC, José P, Edivaldo U, Samir R. A Brazilian survey regarding the management of acute pancreatitis. Revista do Colégio Brasileiro de Cirurgiões, 2008. p. 304-10..

METHODS

A systematic review of the medical literature, based on recommendations of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyzes) protocol, was carried out in studies conducted with humans, which were published in English and Portuguese languages, from 10/25/2012 to 11/30/2018. The search was performed in electronic databases such as PubMed/Medline, SciELO and Cochrane, based on the following descriptors/Boolean operator: “Acute pancreatitis” AND “Atlanta”2626. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62:1006‐12.,2727. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration, 2011.. Inclusion and exclusion criteria were applied and a qualitative analysis of the studies was performed to select valid and eligible articles for future inferences disclosed in the current review.

Inclusion criteria

Only articles meeting the following characteristics were included in the study: 1. Randomized Clinical Trials-type studies; 2. Studies comparing the efficiency of prognostic markers (chemical/biological/clinical parameter) to established concepts, after the Atlanta Classification revision, in order to determine the severity of patients with acute pancreatitis; 3. Studies focused on investigating parameters and/or prognostic markers for acute pancreatitis, based on criteria established after the Atlanta Classification revision - even if only to divide the groups evaluated in the study sample; 4. Studies comparing rating scores and prognosis predictors for the classification and determination of acute pancreatitis severity cases (among them, the criteria established after the Atlanta Classification revision); 5. Studies focused on presenting the clinical evolution of acute pancreatitis with, or without, therapeutic intervention and on determining the severity of patients based on recommendations established after the Atlanta Classification revision; 6. Studies aimed at evaluating or validating the recommendations established after the Atlanta Classification revision.

Exclusion criteria

We excluded studies that did not meet the inclusion criteria, as well as those that did not mention the recommendations established after the Atlanta Classification revision (i.e., studies published after 2012, whose implementation and/or data collection were performed before this year, when the Atlanta Classification revision had not yet been published and, consequently, released for consultation).

Data extraction and qualitative analysis

The search for studies was based on pre-established qualitative criteria, as described in the methodology of the current review. The information was collected and recorded in a standardized Excel data sheet (Microsoft Corp., Redmond, WA). Discrepancies identified during data sorting or throughout the extraction process were resolved through consensus among the authors. The initial qualitative selection of the studies was based on ABSTRACT reading in order to analyze the aims and outcomes, according to pre-established inclusion and exclusion criteria. Subsequently, the selected studies were fully read to enable66. Guo Q, Li M, Chen Y, Hu W. Pancreatology Determinant-based classification and revision of the Atlanta classification, which one should we choose to categorize acute pancreatitis? Pancreatology. 2015;1-6.

7. Chen Y, Ke L, Tong Z, Li W, Li J. Association between severity and the determinant-based classification, Atlanta 2012 and Atlanta 1992, in acute pancreatitis: a clinical retrospective study. Medicine (Baltimore). 2015;94(13):e638.

8. Kadiyala V, Suleiman SL, McNabb-Baltar J, Wu BU, Banks PA, Singh VK. The Atlanta Classification, Revised Atlanta Classification, and Determinant-Based Classification of Acute Pancreatitis: Which Is Best at Stratifying Outcomes? Pancreas. 2016;45:510‐5.
-99. Bansal SS, Hodson J, Sutcliffe RS, Sutcliffe RS, Marudanayagam R, Muiesan P, et al. Performance of the revised Atlanta and determinant-based classifications for severity in acute pancreatitis. Br J Surg. 2016;103:427‐33.,1111. Fernandes SR, Carvalho J, Santos P, Moura CM, Antunes T, Velosa J. Atlanta, revised Atlanta, and Determinant-based classification--application in a cohort of Portuguese patients with acute pancreatitis. Eur J Gastroenterol Hepatol. 2016;28:20‐4.,1616. Deng LH, Hu C, Cai WH, Chen WW, Zhang XX, Shi N, et al. Plasma cytokines can help to identify the development of severe acute pancreatitis on admission. Medicine (Baltimore). 2017;96:e7312.,2828. Schmidt K, Büning J, Weitz G, Woitalla J, Wellh P, Fellermann K. Detrimental effect of high volume fluid administration in acute pancreatitis e A retrospective analysis of 391 patients. Pancreatology. 2014;14:478-83.

29. Karabulut U, Koyuncu MB, Sezgin O, Ucbilek E, Aydin MK, Altintas E. Mo1327 Early Oral Feeding and Selection of Initial Diet in Mild Acute Pancreatitis. Gastroenterology. 2014;146(5):S-621.

30. Beduschi MG, Mello AL, VON-Mühlen B, Franzon O. The panc 3 score predicting severity of acute pancreatitis. Arq Bras Cir Dig . 2016;29:5-8.

31. Sun Y, Lu Z, Zhang X, Geng X, Cao L, Yin L. Pancreatology. The effects of fluid resuscitation according to PiCCO on the early stage of severe acute pancreatitis. Pancreatology. 2015.

32. Zhu Y, Pan X, Zeng H, Xia L, Liu P, Lv N. A Study on the Etiology, Severity, and Mortality of 3260 Patients With Acute Pancreatitis According to the Revised Atlanta Classification in Jiangxi, China Over an 8-Year Period. Pancreas, 2017;46:504-9.

33. Zeng Y, Zhang W, Lu Y, Huang C, Wang X. Impact of hypertriglyceridemia on the outcome of acute biliary pancreatitis. Am J Med Sci. 2014;348:399‐402.

34. Li G, Wang X, Shen X, Ke L, Li W, Tong Z, Zhou J. Positive end-expiratory pressure setting guided by esophageal pressure in patients with intra-abdominal hypertension: a prosp ective, randomized, open-label trial; Pancreatology, 2016;16:S25.

35. Lin S, Hong W, Basharat Z, Wang Q, Pan J, Zhou M. Blood Urea Nitrogen as a Predictor of Severe Acute Pancreatitis Based on the Revised Atlanta Criteria: Timing of Measurement and Cutoff Points. 2017;2017.

36. Qi X, Yang F, Huang H, Du Y, Chen Y, Wang M, et al. OPEN A reduced lymphocyte ratio as an early marker for predicting acute pancreatitis. Nat Publ Gr. 2017;(415):1-6.

37. Jia R, Tang M, Qiu L, Sun R, Cheng L, Ma X, et al. Increased interleukin-23/17 axis and C-reactive protein are associated with severity of acute pancreatitis in patients. Pancreas. 2015;44:321‐5.

38. Shen X, Sun J, Ke L, Zou L, Li B, Tong Z, Li W, Li N, Li J. Reduced lymphocyte count as an early marker for predicting infected pancreatic necrosis. BMC Gastroenterol. 2015;15:147.

39. Kim TN, Kim SB, Cho JH, Kim KH. Comparison of clinical course and outcome of acute pancreatitis according to two main etiologies: alcohol vs. gallstone. Pancreatology. 2009;14(3):S62.

40. Huh JH, Jung S, Cho SK, Lee KJ, Kim JW. Predictive value of apolipoprotein B and A-I ratio in severe acute pancreatitis. J Gastroenterol Hepatol. 2018;33:548-53.

41. Kim BG, Noh MH, Ryu CH, Nam HS, Woo SM, Ryu SH, et al. A comparison of the BISAP score and serum procalcitonin for predicting the severity of acute pancreatitis. Korean J Intern Med. 2013;28:322‐9.

42. Kim J, Cho JH, Kim EJ, Kim Y, Kim HM, Kim Y. Mo1253 - Risk Factors of Recurrent Acute Pancreatitis and Progression to Chronic Pancreatitis after the first Attack of Acute Pancreatitis. Gastroenterology. 2018;154:S-721-S-722.

43. Mikolasevic I, Orlic L, Poropat G, Jakopcic I, Stimac D, Klanac A, et al. European Journal of Internal Medicine Nonalcoholic fatty liver and the severity of acute pancreatitis. Eur J Intern Med. 2017 Mar;38:73-78.

44. Mikolasevic I, Milic S, Orlic L, Poropat G, Jakopcic I, Franjic N, et al. Metabolic syndrome and acute pancreatitis. Eur J Intern Med . 2016

45. Trgo G, Zaja I, Bogut A, Kovacic V, Meter I, Vucic LM, et al. Association of Asymmetric Dimethylarginine With Acute Pancreatitis-Induced Hyperglycemia. Pancreas. 2016;45:694-99.

46. Vujasinovic M, Tepes B, Makuc J, Rudolf S, Zaletel J, Vidmar T, et al. Pancreatic exocrine insufficiency, diabetes mellitus and serum nutritional markers after acute pancreatitis. World J Gastroenterol. 2014;20(48):18432‐8.

47. Pintado M, Trascasa M, Arenillas C, Ortiz Y, Zárate D, Pardo A, et al. European Journal of Internal Medicine. New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis. Eur J Intern Med . 2016;30:82-87.

48. Bozhychko M, Cárdenas-Jaén K, Ruiz-Rebollo ML, de Madaria E. Use of statins and nonsteroidal anti-inflammatory drugs and severity of acute pancreatitis. Pancreatology, 2017. 17(5), S12.

49. Ellery KM, Ms DO, Kumar S, Mmm WC, Gariepy C. The Benefits of Early Oral Nutrition in Mild Acute Pancreatitis. J Pediatr. 2017;1-6.

50. Sugimoto M, Sonntag DP, Flint GS, Boyce CJ, Kirkham JC, Harris TJ, et al. A percutaneous drainage protocol for severe and moderately severe acute pancreatitis. Surg Endosc. 2015;29:3282‐91.

51. Gougol A, Dugum M, Dudekula A, Greer P, Slivka A, Whitcomb DC, et al. Clinical outcomes of isolated renal failure compared to other forms of organ failure in patients with severe acute pancreatitis. World J Gastroenterol . 2017;23:5431‐7.

52. Vipperla K, Somerville C, Furlan A, Koutroumpakis E, Saul M, Chennat J, et al. Clinical Profile and Natural Course in a Large Cohort of Patients With Hypertriglyceridemia and Pancreatitis. J Clin Gastroenterol. 2017;51:77‐85.

53. Vlada AC, Schmit B, Perry A, Trevino JG, Behrns KE, Hughes SJ. Failure to follow evidence-based best practice guidelines in the treatment of severe acute pancreatitis. HPB (Oxford). 2013;822-7.

54. Buxbaum JL, Quezada M, Da B, Jani N, Lane C, Mwengela D, et al. Early Aggressive Hydration Hastens Clinical Improvement in Mild Acute Pancreatitis. Am J Gastroenterol . 2017;112:797‐803.

55. Buxbaum JL, Da B, Quezada M, Jani N, Mwengela D, Thomas E, et al. S-64 AGA Abstracts. Gastroenterology. 2016;150:S64-5.

56. Dimagno MJ, Wamsteker E, Rizk RS, Spaete JP, Gupta S, Sahay T, et al. A Combined Paging Alert and Web-Based Instrument Alters Clinician Behavior and Pancreatitis. Am J Gastroenterol . 2014;109:306-15.

57. Bishu S, Koutroumpakis E, Mounzer R, Stello K, Pollock N, Evans A, Papachristou G. The-251 A/T Polymorphism in the IL8 Promoter is a Risk Factor for Acute Pancreatitis. Pancreas. 2018;47:87-91.

58. Da B, Quezada M, Shulman I, Sheibani S, Buxbaum JL. Severe Obesity Predicts Adverse Outcomes in Acute Pancreatitis. American Journal of Gastroenterology. 2015;110:S14. https://doi.org/10.1038/ajg.2015.269.
https://doi.org/https://doi.org/10.1038/...

59. Nieminen A, Maksimow M, Mentula P, Kyhälä L, Kylänpää L, Puolakkainen P, et al. Circulating cytokines in predicting development of severe acute pancreatitis. Crit Care. 2014;18:R104.

60. Nikkola A, Aittoniemi J, Huttunen R, Rajala L, Nordback I, Sand J, et al. Plasma Level of Soluble Urokinase-type Plasminogen Activator Receptor Predicts the Severity of Acute Alcohol Pancreatitis. Pancreas. 2017;46:77‐82.

61. Nukarinen E, Lindström O, Kuuliala K, Kylänpää L, Pettilä V, Puolakkainen P, et al. Association of Matrix Metalloproteinases -7, -8 and -9 and TIMP -1 with Disease Severity in Acute Pancreatitis. A Cohort Study. PLoS One. 2016;11:e0161480.

62. Bakker OJ, van Santvoort H, Besselink MG, Boermeester MA, van Eijck C, Dejong K, et al. Extrapancreatic necrosis without pancreatic parenchymal necrosis: a separate entity in necrotising pancreatitis? Gut. 2013;62:1475‐80.

63. Párniczky A, Mosztbacher D, Zsoldos F, Tóth A, Lásztity N, Hegyi P, et al. Analysis of Pediatric Pancreatitis (APPLE Trial): Pre-Study Protocol of a Multinational Prospective Clinical Trial. Digestion. 2016;93:105‐10.

64. Doley RP, Yadav TD, Wig JD, Kochhar R, Singh G, Bharathy KG, et al. Enteral nutrition in severe acute pancreatitis. JOP. 2009;10:157‐62.

65. John BJ, Sambandam S, Garg P, Singh G, Kaur M, Baskaran R, et al. Persistent Systemic Inflammatory Response Syndrome predicts the need for tertiary care in Acute Pancreatitis. Acta Gastroenterol Belg. 2017;80:377‐80.

66. Stirling AD, Moran NR, Kelly ME, Ridgway PF, Conlon KC. The predictive value of C-reactive protein (CRP) in acute pancreatitis - is interval change in CRP an additional indicator of severity? HPB (Oxford). 2017;19:874-80.

67. Losurdo G, Iannone A, Principi M, Barone M, Ranaldo N, Ierardi E, et al. European Journal of Internal Medicine Acute pancreatitis in elderly patients: A retrospective evaluation at hospital admission. Eur J Intern Med . 2016;30:88-93.

68. Sugawara S, Arai Y, Sone M, Katai H. Frequency, severity, and risk factors for acute pancreatitis after percutaneous transhepatic biliary stent placement across the papilla of vater. Cardiovasc Intervent Radiol. 2017;40:1904-10.

69. Karpavicius A, Dambrauskas Z, Gradauskas A, Samuilis A, Zviniene K, Kupcinskas J, et al. The clinical value of adipokines in predicting the severity and outcome of acute pancreatitis. BMC Gastroenterol . 2016;16:99.

70. Chacón-portillo MA, Payró-ramírez G, Peláez-luna MC, Uscanga-domínguez LF, Vasquéz-ortiz Z, Orihuela C, et al. Abnormal Cardiovascular Findings in Acute Pancreatitis: Are They Associated with Disease Severity ? Rev Inves Clin. 2017;314-8.

71. Riquelme F, Marinkovic B, Salazar M, Martínez W, Catan F, Uribe-Echevarría S, et al. Early laparoscopic cholecystectomy reduces hospital stay in mild gallstone pancreatitis. A randomized controlled trial. HPB (Oxford). 2020;22:26‐33.

72. Cuellar-Monterrubio JE, Robles RM, Gonzalez-Moreno EI, Borjas-Almaguer OD, Garcia-Compean D, Maldonado Garza HJ, González-González JA. Guidelines Versus Directed IV Fluid Therapy in Acute Pancreatitis of More than 24 Hours of Clinical Evolution: A Prospective Randomized Clinical Trial Gastroenterology. Gastroenterology 2017;152(5):S281. DOI: 10.1016/S0016-5085(17)31235-0.
https://doi.org/10.1016/S0016-5085(17)31...

73. Głuszek S, Nawacki Ł, Matykiewicz J, Kot M, Kuchinka J. Severe Vascular Complications Of Acute Pancreatitis. Pol Przegl Chir. 2015;87:485‐90.

74. Madaria E, Herrera-Marante I, Gonzalez-Camacho V, Bonjoch L, Quesada-Vazquez N, Almenta-Saavedra I, et al. Fluid resuscitation with lactated Ringer’s solution vs normal saline in acute pancreatitis: A triple-blind, randomized, controlled trial. HPB (Oxford). 2018;6:63-72.

75. Kuśnierz-Cabala B, Gala-Błądzińska A, Mazur-Laskowska M, Dumnicka P, Sporek M, Matuszyk A, et al. Serum Uromodulin Levels in Prediction of Acute Kidney Injury in the Early Phase of Acute Pancreatitis. Molecules. 2017;22:988.

76. Sporek M, Dumnicka P, Gala-Błądzińska A, Małgorzata Mazur-Laskowska, Walocha J, Ceranowicz P, et al. Determination of serum neutrophil gelatinase-associated lipocalin at the early stage of acute pancreatitis. Folia Med Cracov. 2016;56:5‐16.

77. Huggett MT, Oppong KW, Pereira SP, Keane MG, Mitra V, Charnley RM, Nayar MK. Endoscopic drainage of walled-off pancreatic necrosis using a novel self-expanding metal stent. Endoscopy. 2015;47:929‐32.

78. Suppiah A, Malde D, Arab T, Hamed M, Allgar V, Smith AM, Morris-Stiff G. The prognostic value of the neutrophil-lymphocyte ratio (NLR) in acute pancreatitis: identification of an optimal NLR. J Gastrointest Surg. 2013;17:675‐81.

79. Haffar S, Bazerbachi F, Prokop L, Watt KD, Murad MH, Chari ST. Frequency and prognosis of acute pancreatitis associated with fulminant or non-fulminant acute hepatitis A: A systematic review. Pancreatology. 2017;17:166-75.

80. Bertilsson S, Swärd P, Kalaitzakis E. Factors That Affect Disease Progression After First Attack of Acute Pancreatitis. Clin Gastroenterol Hepatol. 2015;13:1662-9.e3.

81. Ragnarsson T, Andersson R, Ansari D, Persson U, Andersson B. Acute biliary pancreatitis: focus on recurrence rate and costs when current guidelines are not complied. Scand J Gastroenterol. 2017;52:264‐9.

82. Shen HN, Chang YH, Chen HF, Lu CL, Li CY. Increased risk of severe acute pancreatitis in patients with diabetes. Diabet Med. 2012;29:1419‐24.

83. İnce AT, Senturk H, Singh VK, Yildiz K, Danalioğlu A, Çinar A, et al. A randomized controlled trial of home monitoring versus hospitalization for mild non-alcoholic acute interstitial pancreatitis: A pilot study. Pancreatology. 2014;14:174-8.

84. de-Madaria E, Herrera-Marante I, González-Camacho V, Bonjoch L, Quesada-Vázquez N, Almenta-Saavedra I, et al. Fluid resuscitation with lactated Ringer’s solution vs normal saline in acute pancreatitis: A triple-blind, randomized, controlled trial. United European Gastroenterol J. 2018;6:63-72.

85. Tozlu M, Kayar Y, İnce AT, Baysal B, Şentürk H. Low molecular weight heparin treatment of acute moderate and severe pancreatitis: A randomized, controlled open-label study. Turk J Gastroenterol. 2019;30:81‐7.

86. Fidan S, Erkut M, Cosar AM, Yogun Y, Örem A, Sönmez M, Arslan M. Higher Thrombin-Antithrombin III Complex Levels May Indicate Severe Acute Pancreatitis. Dig Dis. 2018;36:244‐51.

87. Abdullah B, Dusak A, Kaplan I, Gümüs M. The potential role of BMI, plasma leptin, nesfatin-1 and ghrelin levels in the early detection of pancreatic necrosis and severe acute pancreatitis: A prospective cohort study. Int J Surg. 2014;12:1310-3.

88. Koziel D, Gluszek S, Matykiewicz J, Lewitowicz P, Drozdzak Z. Comparative analysis of selected scales to assess prognosis in acute pancreatitis. Can J Gastroenterol Hepatol . 2015;29:299-303.

89. Liu J, Cao F, Dong XM, Yu Li P, Li HC, Qi BJ, Li F. Early prediction of organ failure under the revised Atlanta classification. Turk J Gastroenterol . 2017;28:46‐52.

90. He WH, Zhu Y, Zhu Y, Jin Q, Xu HR, Xion ZJ, et al. Comparison of multifactor scoring systems and single serum markers for the early prediction of the severity of acute pancreatitis. J Gastroenterol Hepatol . 2017;32:1895‐901.

91. Zhang J, Shahbaz M, Fang R, Liang B, Gao C, Gao H, et al. Comparison of the BISAP scores for predicting the severity of acute pancreatitis in Chinese patients according to the latest Atlanta classification. J Hepatobiliary Pancreat Sci. 2014;21:689‐94.

92. Xu XD, Wang ZY, Zhang LY, Ni R, Wei FX, Han W, et al. Acute Pancreatitis Classifications: Basis and Key Goals. Medicine (Baltimore). 2015;94:e2182.

93. Yang Z, Dong L, Zhang Y, Yang C, Gou S, Li Y, et al. Prediction of Severe Acute Pancreatitis Using a Decision Tree Model Based on the Revised Atlanta Classification of Acute Pancreatitis. PLoS One. 2015;10:e0143486.

94. Lee KJ, Kim HM, Choi JS, Kim YJ, Kim YS, Cho JH. Comparison of Predictive Systems in Severe Acute Pancreatitis According to the Revised Atlanta Classification. Pancreas. 2016;45:46‐50.

95. Zubia-Olaskoaga F, Maraví-Poma E, Urreta-Barallobre I, Ramírez-Puerta MR, Mourelo-Fariña M, Marcos-Neira MP, et al. Comparison Between Revised Atlanta Classification and Determinant-Based Classification for Acute Pancreatitis in Intensive Care Medicine. Why Do Not Use a Modified Determinant-Based Classification? Crit Care Med. 2016;44:910‐7.

96. Acevedo-Piedra NG, Moya-Hoyo N, Rey-Riveiro M, Gil S, Laura S, Juan M, et al. Validation of the determinant-based classification and revision of the Atlanta classification systems for acute pancreatitis. Clin Gastroenterol Hepatol . 2014;12:311‐6.

97. Nawaz H, Mounzer R, Yadav D, Yabes JG, Slivka A. Revised Atlanta and Determinant-Based Classifi cation : Application in a Prospective Cohort of Acute Pancreatitis Patients. Am J Gastroenterol [Internet]. 2013;108:1911-7.

98. Jones MJ, Neal CP, Ngu WS, Dennison AR, Garcea G. Early warning score independently predicts adverse outcome and mortality in patients with acute pancreatitis. Langenbecks Arch Surg. 2017;402:811-9.

99. Ikeura T, Horibe M, Sanui M, Sasaki M, Kuwagata Y, Nishi K, Kariya S, et al. Validation of the efficacy of the prognostic factor score in the Japanese severity criteria for severe acute pancreatitis: A large multicenter study. United European Gastroenterol J . 2017;5:389-97.

100. Gravito-Soares M, Gravito-Soares E, Gomes D, Almeida N, Tomé L. Red cell distribution width and red cell distribution width to total serum calcium ratio as major predictors of severity and mortality in acute pancreatitis. BMC Gastroenterol . 2018;18:108.

101. Chen C, Huang Z, Li H, Song B, Yuan F. Evaluation of extrapancreatic inflammation on abdominal computed tomography as an early predictor of organ failure in acute pancreatitis as defined by the revised Atlanta classification. Medicine (Baltimore). 2017;96(15).

102. Huang J, Qu H, Zheng Y, Song X, Li L, Xu Z. The revised Atlanta criteria 2012 altered the classification, severity assessment and management of acute pancreatitis. Hepatobiliary Pancreat Dis Int.. 2016;15:310-5.

103. Choi J, Kim M, Oh D, Hyun W, Hyun D, Soo S, et al. Clinical relevance of the revised Atlanta classification focusing on severity stratification system. Pancreatology. 2014;14:324-9.

104. Kim EJ, Cho JH, Oh KY, Kim SY, Kim YS. The Risk Factors for Moderately Severe and Severe Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis According to the Revised Atlanta Classification. Pancreas. 2017;46:1208-13.

105. Bouwense SA, van Brunschot S, van Santvoort HC, Besselink MG, Bollen TL, Bakker OJ, et al. Describing Peripancreatic Collections According to the Revised Atlanta Classification of Acute Pancreatitis: An International Interobserver Agreement Study. Pancreas. 2017;46:850‐7.

106. Talukdar R, Bhattacharrya A, Rao B, Sharma M, Reddy DN. Pancreatology Clinical utility of the Revised Atlanta Classification of acute pancreatitis in a prospective cohort: Have all loose ends been tied? Pancreatology. 2014;14:257-62.

107. Thandassery RB, Yadav TD, Dutta U, Appasani S, Singh K, Kochhar R. Prospective validation of 4-category classification of acute pancreatitis severity. Pancreas. 2013;42:392‐6.

108. Ignatavicius P, Gulla A, Cernauskis K, Barauskas G, Dambrauskas Z. How severe is moderately severe acute pancreatitis? Clinical validation of revised 2012 Atlanta Classification. World J Gastroenterol . 2017;23(43):7785-90.

109. Lakhey PJ, Bhandari RS, Kafle B, Singh KP, Khakurel M. Validation of ‘Moderately Severe Acute Pancreatitis’ in patients with Acute Pancreatitis. JNMA J Nepal Med Assoc. 2013;52:580-5.
-110110. Gluszek S, Kozie D. Prevalence and progression of acute pancreatitis in the świętokrzyskie voivodeship population. Pol Przegl Chir . 2012;84:618-25..

Exceptionally, in order to clarify some discussion points, the search in the databases was extended to studies presenting design different from the randomized clinical trial, a fact that enabled using more than one study111111. Staubli SM, Oertli D, Nebiker CA. Assessing the severity of acute pancreatitis (ASAP) in Switzerland: a nationwide survey on severity assessment in daily clinical practice. Pancreatology. 2017;7:356-63.. However, according to the inclusion and exclusion criteria of this review, the selected study, which presented different design from the clinical trial, was not taken into consideration in the results, nor was it added to the tables, in order to respect the methodological proposal of this systematic review111111. Staubli SM, Oertli D, Nebiker CA. Assessing the severity of acute pancreatitis (ASAP) in Switzerland: a nationwide survey on severity assessment in daily clinical practice. Pancreatology. 2017;7:356-63..

RESULTS

One hundred and seventy-four (174) studies were initially identified. Next, they were subjected to the inclusion and exclusion criteria and to qualitative analysis (according to the PRISMA protocol), which made it possible selecting 89 valid studies, as shown in Figure 1 2626. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62:1006‐12.,2727. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration, 2011..

FIGURE 1
Outlining the selection of valid studies based on PRISMA Protocol.

The herein selected 89 valid studies were recorded and stratified as to whether, or not, they applied the recommendations and/or concepts proposed and disclosed after the Atlanta Classification revision. The studies applying these recommendations were those that, based on these principles, established and determined the severity of the investigated patients (mild, moderately severe, severe) in order to evaluate their clinical evolution (Table 1)1616. Deng LH, Hu C, Cai WH, Chen WW, Zhang XX, Shi N, et al. Plasma cytokines can help to identify the development of severe acute pancreatitis on admission. Medicine (Baltimore). 2017;96:e7312.,2828. Schmidt K, Büning J, Weitz G, Woitalla J, Wellh P, Fellermann K. Detrimental effect of high volume fluid administration in acute pancreatitis e A retrospective analysis of 391 patients. Pancreatology. 2014;14:478-83.

29. Karabulut U, Koyuncu MB, Sezgin O, Ucbilek E, Aydin MK, Altintas E. Mo1327 Early Oral Feeding and Selection of Initial Diet in Mild Acute Pancreatitis. Gastroenterology. 2014;146(5):S-621.

30. Beduschi MG, Mello AL, VON-Mühlen B, Franzon O. The panc 3 score predicting severity of acute pancreatitis. Arq Bras Cir Dig . 2016;29:5-8.

31. Sun Y, Lu Z, Zhang X, Geng X, Cao L, Yin L. Pancreatology. The effects of fluid resuscitation according to PiCCO on the early stage of severe acute pancreatitis. Pancreatology. 2015.

32. Zhu Y, Pan X, Zeng H, Xia L, Liu P, Lv N. A Study on the Etiology, Severity, and Mortality of 3260 Patients With Acute Pancreatitis According to the Revised Atlanta Classification in Jiangxi, China Over an 8-Year Period. Pancreas, 2017;46:504-9.

33. Zeng Y, Zhang W, Lu Y, Huang C, Wang X. Impact of hypertriglyceridemia on the outcome of acute biliary pancreatitis. Am J Med Sci. 2014;348:399‐402.

34. Li G, Wang X, Shen X, Ke L, Li W, Tong Z, Zhou J. Positive end-expiratory pressure setting guided by esophageal pressure in patients with intra-abdominal hypertension: a prosp ective, randomized, open-label trial; Pancreatology, 2016;16:S25.

35. Lin S, Hong W, Basharat Z, Wang Q, Pan J, Zhou M. Blood Urea Nitrogen as a Predictor of Severe Acute Pancreatitis Based on the Revised Atlanta Criteria: Timing of Measurement and Cutoff Points. 2017;2017.

36. Qi X, Yang F, Huang H, Du Y, Chen Y, Wang M, et al. OPEN A reduced lymphocyte ratio as an early marker for predicting acute pancreatitis. Nat Publ Gr. 2017;(415):1-6.

37. Jia R, Tang M, Qiu L, Sun R, Cheng L, Ma X, et al. Increased interleukin-23/17 axis and C-reactive protein are associated with severity of acute pancreatitis in patients. Pancreas. 2015;44:321‐5.

38. Shen X, Sun J, Ke L, Zou L, Li B, Tong Z, Li W, Li N, Li J. Reduced lymphocyte count as an early marker for predicting infected pancreatic necrosis. BMC Gastroenterol. 2015;15:147.

39. Kim TN, Kim SB, Cho JH, Kim KH. Comparison of clinical course and outcome of acute pancreatitis according to two main etiologies: alcohol vs. gallstone. Pancreatology. 2009;14(3):S62.

40. Huh JH, Jung S, Cho SK, Lee KJ, Kim JW. Predictive value of apolipoprotein B and A-I ratio in severe acute pancreatitis. J Gastroenterol Hepatol. 2018;33:548-53.

41. Kim BG, Noh MH, Ryu CH, Nam HS, Woo SM, Ryu SH, et al. A comparison of the BISAP score and serum procalcitonin for predicting the severity of acute pancreatitis. Korean J Intern Med. 2013;28:322‐9.

42. Kim J, Cho JH, Kim EJ, Kim Y, Kim HM, Kim Y. Mo1253 - Risk Factors of Recurrent Acute Pancreatitis and Progression to Chronic Pancreatitis after the first Attack of Acute Pancreatitis. Gastroenterology. 2018;154:S-721-S-722.

43. Mikolasevic I, Orlic L, Poropat G, Jakopcic I, Stimac D, Klanac A, et al. European Journal of Internal Medicine Nonalcoholic fatty liver and the severity of acute pancreatitis. Eur J Intern Med. 2017 Mar;38:73-78.

44. Mikolasevic I, Milic S, Orlic L, Poropat G, Jakopcic I, Franjic N, et al. Metabolic syndrome and acute pancreatitis. Eur J Intern Med . 2016

45. Trgo G, Zaja I, Bogut A, Kovacic V, Meter I, Vucic LM, et al. Association of Asymmetric Dimethylarginine With Acute Pancreatitis-Induced Hyperglycemia. Pancreas. 2016;45:694-99.

46. Vujasinovic M, Tepes B, Makuc J, Rudolf S, Zaletel J, Vidmar T, et al. Pancreatic exocrine insufficiency, diabetes mellitus and serum nutritional markers after acute pancreatitis. World J Gastroenterol. 2014;20(48):18432‐8.

47. Pintado M, Trascasa M, Arenillas C, Ortiz Y, Zárate D, Pardo A, et al. European Journal of Internal Medicine. New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis. Eur J Intern Med . 2016;30:82-87.

48. Bozhychko M, Cárdenas-Jaén K, Ruiz-Rebollo ML, de Madaria E. Use of statins and nonsteroidal anti-inflammatory drugs and severity of acute pancreatitis. Pancreatology, 2017. 17(5), S12.

49. Ellery KM, Ms DO, Kumar S, Mmm WC, Gariepy C. The Benefits of Early Oral Nutrition in Mild Acute Pancreatitis. J Pediatr. 2017;1-6.

50. Sugimoto M, Sonntag DP, Flint GS, Boyce CJ, Kirkham JC, Harris TJ, et al. A percutaneous drainage protocol for severe and moderately severe acute pancreatitis. Surg Endosc. 2015;29:3282‐91.

51. Gougol A, Dugum M, Dudekula A, Greer P, Slivka A, Whitcomb DC, et al. Clinical outcomes of isolated renal failure compared to other forms of organ failure in patients with severe acute pancreatitis. World J Gastroenterol . 2017;23:5431‐7.

52. Vipperla K, Somerville C, Furlan A, Koutroumpakis E, Saul M, Chennat J, et al. Clinical Profile and Natural Course in a Large Cohort of Patients With Hypertriglyceridemia and Pancreatitis. J Clin Gastroenterol. 2017;51:77‐85.

53. Vlada AC, Schmit B, Perry A, Trevino JG, Behrns KE, Hughes SJ. Failure to follow evidence-based best practice guidelines in the treatment of severe acute pancreatitis. HPB (Oxford). 2013;822-7.

54. Buxbaum JL, Quezada M, Da B, Jani N, Lane C, Mwengela D, et al. Early Aggressive Hydration Hastens Clinical Improvement in Mild Acute Pancreatitis. Am J Gastroenterol . 2017;112:797‐803.

55. Buxbaum JL, Da B, Quezada M, Jani N, Mwengela D, Thomas E, et al. S-64 AGA Abstracts. Gastroenterology. 2016;150:S64-5.

56. Dimagno MJ, Wamsteker E, Rizk RS, Spaete JP, Gupta S, Sahay T, et al. A Combined Paging Alert and Web-Based Instrument Alters Clinician Behavior and Pancreatitis. Am J Gastroenterol . 2014;109:306-15.

57. Bishu S, Koutroumpakis E, Mounzer R, Stello K, Pollock N, Evans A, Papachristou G. The-251 A/T Polymorphism in the IL8 Promoter is a Risk Factor for Acute Pancreatitis. Pancreas. 2018;47:87-91.

58. Da B, Quezada M, Shulman I, Sheibani S, Buxbaum JL. Severe Obesity Predicts Adverse Outcomes in Acute Pancreatitis. American Journal of Gastroenterology. 2015;110:S14. https://doi.org/10.1038/ajg.2015.269.
https://doi.org/https://doi.org/10.1038/...

59. Nieminen A, Maksimow M, Mentula P, Kyhälä L, Kylänpää L, Puolakkainen P, et al. Circulating cytokines in predicting development of severe acute pancreatitis. Crit Care. 2014;18:R104.

60. Nikkola A, Aittoniemi J, Huttunen R, Rajala L, Nordback I, Sand J, et al. Plasma Level of Soluble Urokinase-type Plasminogen Activator Receptor Predicts the Severity of Acute Alcohol Pancreatitis. Pancreas. 2017;46:77‐82.

61. Nukarinen E, Lindström O, Kuuliala K, Kylänpää L, Pettilä V, Puolakkainen P, et al. Association of Matrix Metalloproteinases -7, -8 and -9 and TIMP -1 with Disease Severity in Acute Pancreatitis. A Cohort Study. PLoS One. 2016;11:e0161480.

62. Bakker OJ, van Santvoort H, Besselink MG, Boermeester MA, van Eijck C, Dejong K, et al. Extrapancreatic necrosis without pancreatic parenchymal necrosis: a separate entity in necrotising pancreatitis? Gut. 2013;62:1475‐80.

63. Párniczky A, Mosztbacher D, Zsoldos F, Tóth A, Lásztity N, Hegyi P, et al. Analysis of Pediatric Pancreatitis (APPLE Trial): Pre-Study Protocol of a Multinational Prospective Clinical Trial. Digestion. 2016;93:105‐10.

64. Doley RP, Yadav TD, Wig JD, Kochhar R, Singh G, Bharathy KG, et al. Enteral nutrition in severe acute pancreatitis. JOP. 2009;10:157‐62.

65. John BJ, Sambandam S, Garg P, Singh G, Kaur M, Baskaran R, et al. Persistent Systemic Inflammatory Response Syndrome predicts the need for tertiary care in Acute Pancreatitis. Acta Gastroenterol Belg. 2017;80:377‐80.

66. Stirling AD, Moran NR, Kelly ME, Ridgway PF, Conlon KC. The predictive value of C-reactive protein (CRP) in acute pancreatitis - is interval change in CRP an additional indicator of severity? HPB (Oxford). 2017;19:874-80.

67. Losurdo G, Iannone A, Principi M, Barone M, Ranaldo N, Ierardi E, et al. European Journal of Internal Medicine Acute pancreatitis in elderly patients: A retrospective evaluation at hospital admission. Eur J Intern Med . 2016;30:88-93.

68. Sugawara S, Arai Y, Sone M, Katai H. Frequency, severity, and risk factors for acute pancreatitis after percutaneous transhepatic biliary stent placement across the papilla of vater. Cardiovasc Intervent Radiol. 2017;40:1904-10.

69. Karpavicius A, Dambrauskas Z, Gradauskas A, Samuilis A, Zviniene K, Kupcinskas J, et al. The clinical value of adipokines in predicting the severity and outcome of acute pancreatitis. BMC Gastroenterol . 2016;16:99.

70. Chacón-portillo MA, Payró-ramírez G, Peláez-luna MC, Uscanga-domínguez LF, Vasquéz-ortiz Z, Orihuela C, et al. Abnormal Cardiovascular Findings in Acute Pancreatitis: Are They Associated with Disease Severity ? Rev Inves Clin. 2017;314-8.

71. Riquelme F, Marinkovic B, Salazar M, Martínez W, Catan F, Uribe-Echevarría S, et al. Early laparoscopic cholecystectomy reduces hospital stay in mild gallstone pancreatitis. A randomized controlled trial. HPB (Oxford). 2020;22:26‐33.

72. Cuellar-Monterrubio JE, Robles RM, Gonzalez-Moreno EI, Borjas-Almaguer OD, Garcia-Compean D, Maldonado Garza HJ, González-González JA. Guidelines Versus Directed IV Fluid Therapy in Acute Pancreatitis of More than 24 Hours of Clinical Evolution: A Prospective Randomized Clinical Trial Gastroenterology. Gastroenterology 2017;152(5):S281. DOI: 10.1016/S0016-5085(17)31235-0.
https://doi.org/10.1016/S0016-5085(17)31...

73. Głuszek S, Nawacki Ł, Matykiewicz J, Kot M, Kuchinka J. Severe Vascular Complications Of Acute Pancreatitis. Pol Przegl Chir. 2015;87:485‐90.

74. Madaria E, Herrera-Marante I, Gonzalez-Camacho V, Bonjoch L, Quesada-Vazquez N, Almenta-Saavedra I, et al. Fluid resuscitation with lactated Ringer’s solution vs normal saline in acute pancreatitis: A triple-blind, randomized, controlled trial. HPB (Oxford). 2018;6:63-72.

75. Kuśnierz-Cabala B, Gala-Błądzińska A, Mazur-Laskowska M, Dumnicka P, Sporek M, Matuszyk A, et al. Serum Uromodulin Levels in Prediction of Acute Kidney Injury in the Early Phase of Acute Pancreatitis. Molecules. 2017;22:988.

76. Sporek M, Dumnicka P, Gala-Błądzińska A, Małgorzata Mazur-Laskowska, Walocha J, Ceranowicz P, et al. Determination of serum neutrophil gelatinase-associated lipocalin at the early stage of acute pancreatitis. Folia Med Cracov. 2016;56:5‐16.

77. Huggett MT, Oppong KW, Pereira SP, Keane MG, Mitra V, Charnley RM, Nayar MK. Endoscopic drainage of walled-off pancreatic necrosis using a novel self-expanding metal stent. Endoscopy. 2015;47:929‐32.

78. Suppiah A, Malde D, Arab T, Hamed M, Allgar V, Smith AM, Morris-Stiff G. The prognostic value of the neutrophil-lymphocyte ratio (NLR) in acute pancreatitis: identification of an optimal NLR. J Gastrointest Surg. 2013;17:675‐81.

79. Haffar S, Bazerbachi F, Prokop L, Watt KD, Murad MH, Chari ST. Frequency and prognosis of acute pancreatitis associated with fulminant or non-fulminant acute hepatitis A: A systematic review. Pancreatology. 2017;17:166-75.

80. Bertilsson S, Swärd P, Kalaitzakis E. Factors That Affect Disease Progression After First Attack of Acute Pancreatitis. Clin Gastroenterol Hepatol. 2015;13:1662-9.e3.

81. Ragnarsson T, Andersson R, Ansari D, Persson U, Andersson B. Acute biliary pancreatitis: focus on recurrence rate and costs when current guidelines are not complied. Scand J Gastroenterol. 2017;52:264‐9.

82. Shen HN, Chang YH, Chen HF, Lu CL, Li CY. Increased risk of severe acute pancreatitis in patients with diabetes. Diabet Med. 2012;29:1419‐24.

83. İnce AT, Senturk H, Singh VK, Yildiz K, Danalioğlu A, Çinar A, et al. A randomized controlled trial of home monitoring versus hospitalization for mild non-alcoholic acute interstitial pancreatitis: A pilot study. Pancreatology. 2014;14:174-8.

84. de-Madaria E, Herrera-Marante I, González-Camacho V, Bonjoch L, Quesada-Vázquez N, Almenta-Saavedra I, et al. Fluid resuscitation with lactated Ringer’s solution vs normal saline in acute pancreatitis: A triple-blind, randomized, controlled trial. United European Gastroenterol J. 2018;6:63-72.

85. Tozlu M, Kayar Y, İnce AT, Baysal B, Şentürk H. Low molecular weight heparin treatment of acute moderate and severe pancreatitis: A randomized, controlled open-label study. Turk J Gastroenterol. 2019;30:81‐7.

86. Fidan S, Erkut M, Cosar AM, Yogun Y, Örem A, Sönmez M, Arslan M. Higher Thrombin-Antithrombin III Complex Levels May Indicate Severe Acute Pancreatitis. Dig Dis. 2018;36:244‐51.
-8787. Abdullah B, Dusak A, Kaplan I, Gümüs M. The potential role of BMI, plasma leptin, nesfatin-1 and ghrelin levels in the early detection of pancreatic necrosis and severe acute pancreatitis: A prospective cohort study. Int J Surg. 2014;12:1310-3..

TABLE 1
List of studies that applied the recommendations and concepts proposed after the Atlanta Classification revision, establishing the severity of the investigated patients in mild, moderately severe or severe, in order to evaluate their clinical evolution.

Other studies that did not apply these concepts and/or recommendations to categorize patients’ severity were subdivided as follows: studies that just compared the efficiency of prognostic markers (chemical / biological / clinical parameter) and of old rating scores to the new concepts used to determine the severity of patients, which were disclosed after the Atlanta classification revision (Table 2)66. Guo Q, Li M, Chen Y, Hu W. Pancreatology Determinant-based classification and revision of the Atlanta classification, which one should we choose to categorize acute pancreatitis? Pancreatology. 2015;1-6.

7. Chen Y, Ke L, Tong Z, Li W, Li J. Association between severity and the determinant-based classification, Atlanta 2012 and Atlanta 1992, in acute pancreatitis: a clinical retrospective study. Medicine (Baltimore). 2015;94(13):e638.

8. Kadiyala V, Suleiman SL, McNabb-Baltar J, Wu BU, Banks PA, Singh VK. The Atlanta Classification, Revised Atlanta Classification, and Determinant-Based Classification of Acute Pancreatitis: Which Is Best at Stratifying Outcomes? Pancreas. 2016;45:510‐5.
-99. Bansal SS, Hodson J, Sutcliffe RS, Sutcliffe RS, Marudanayagam R, Muiesan P, et al. Performance of the revised Atlanta and determinant-based classifications for severity in acute pancreatitis. Br J Surg. 2016;103:427‐33.,8888. Koziel D, Gluszek S, Matykiewicz J, Lewitowicz P, Drozdzak Z. Comparative analysis of selected scales to assess prognosis in acute pancreatitis. Can J Gastroenterol Hepatol . 2015;29:299-303.

89. Liu J, Cao F, Dong XM, Yu Li P, Li HC, Qi BJ, Li F. Early prediction of organ failure under the revised Atlanta classification. Turk J Gastroenterol . 2017;28:46‐52.

90. He WH, Zhu Y, Zhu Y, Jin Q, Xu HR, Xion ZJ, et al. Comparison of multifactor scoring systems and single serum markers for the early prediction of the severity of acute pancreatitis. J Gastroenterol Hepatol . 2017;32:1895‐901.

91. Zhang J, Shahbaz M, Fang R, Liang B, Gao C, Gao H, et al. Comparison of the BISAP scores for predicting the severity of acute pancreatitis in Chinese patients according to the latest Atlanta classification. J Hepatobiliary Pancreat Sci. 2014;21:689‐94.

92. Xu XD, Wang ZY, Zhang LY, Ni R, Wei FX, Han W, et al. Acute Pancreatitis Classifications: Basis and Key Goals. Medicine (Baltimore). 2015;94:e2182.

93. Yang Z, Dong L, Zhang Y, Yang C, Gou S, Li Y, et al. Prediction of Severe Acute Pancreatitis Using a Decision Tree Model Based on the Revised Atlanta Classification of Acute Pancreatitis. PLoS One. 2015;10:e0143486.

94. Lee KJ, Kim HM, Choi JS, Kim YJ, Kim YS, Cho JH. Comparison of Predictive Systems in Severe Acute Pancreatitis According to the Revised Atlanta Classification. Pancreas. 2016;45:46‐50.

95. Zubia-Olaskoaga F, Maraví-Poma E, Urreta-Barallobre I, Ramírez-Puerta MR, Mourelo-Fariña M, Marcos-Neira MP, et al. Comparison Between Revised Atlanta Classification and Determinant-Based Classification for Acute Pancreatitis in Intensive Care Medicine. Why Do Not Use a Modified Determinant-Based Classification? Crit Care Med. 2016;44:910‐7.

96. Acevedo-Piedra NG, Moya-Hoyo N, Rey-Riveiro M, Gil S, Laura S, Juan M, et al. Validation of the determinant-based classification and revision of the Atlanta classification systems for acute pancreatitis. Clin Gastroenterol Hepatol . 2014;12:311‐6.

97. Nawaz H, Mounzer R, Yadav D, Yabes JG, Slivka A. Revised Atlanta and Determinant-Based Classifi cation : Application in a Prospective Cohort of Acute Pancreatitis Patients. Am J Gastroenterol [Internet]. 2013;108:1911-7.

98. Jones MJ, Neal CP, Ngu WS, Dennison AR, Garcea G. Early warning score independently predicts adverse outcome and mortality in patients with acute pancreatitis. Langenbecks Arch Surg. 2017;402:811-9.

99. Ikeura T, Horibe M, Sanui M, Sasaki M, Kuwagata Y, Nishi K, Kariya S, et al. Validation of the efficacy of the prognostic factor score in the Japanese severity criteria for severe acute pancreatitis: A large multicenter study. United European Gastroenterol J . 2017;5:389-97.
-100100. Gravito-Soares M, Gravito-Soares E, Gomes D, Almeida N, Tomé L. Red cell distribution width and red cell distribution width to total serum calcium ratio as major predictors of severity and mortality in acute pancreatitis. BMC Gastroenterol . 2018;18:108.; and studies that just evaluated and validated the recommendations issued after the Atlanta Classification revision (Table 3)1111. Fernandes SR, Carvalho J, Santos P, Moura CM, Antunes T, Velosa J. Atlanta, revised Atlanta, and Determinant-based classification--application in a cohort of Portuguese patients with acute pancreatitis. Eur J Gastroenterol Hepatol. 2016;28:20‐4.,101101. Chen C, Huang Z, Li H, Song B, Yuan F. Evaluation of extrapancreatic inflammation on abdominal computed tomography as an early predictor of organ failure in acute pancreatitis as defined by the revised Atlanta classification. Medicine (Baltimore). 2017;96(15).

102. Huang J, Qu H, Zheng Y, Song X, Li L, Xu Z. The revised Atlanta criteria 2012 altered the classification, severity assessment and management of acute pancreatitis. Hepatobiliary Pancreat Dis Int.. 2016;15:310-5.

103. Choi J, Kim M, Oh D, Hyun W, Hyun D, Soo S, et al. Clinical relevance of the revised Atlanta classification focusing on severity stratification system. Pancreatology. 2014;14:324-9.

104. Kim EJ, Cho JH, Oh KY, Kim SY, Kim YS. The Risk Factors for Moderately Severe and Severe Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis According to the Revised Atlanta Classification. Pancreas. 2017;46:1208-13.

105. Bouwense SA, van Brunschot S, van Santvoort HC, Besselink MG, Bollen TL, Bakker OJ, et al. Describing Peripancreatic Collections According to the Revised Atlanta Classification of Acute Pancreatitis: An International Interobserver Agreement Study. Pancreas. 2017;46:850‐7.

106. Talukdar R, Bhattacharrya A, Rao B, Sharma M, Reddy DN. Pancreatology Clinical utility of the Revised Atlanta Classification of acute pancreatitis in a prospective cohort: Have all loose ends been tied? Pancreatology. 2014;14:257-62.

107. Thandassery RB, Yadav TD, Dutta U, Appasani S, Singh K, Kochhar R. Prospective validation of 4-category classification of acute pancreatitis severity. Pancreas. 2013;42:392‐6.

108. Ignatavicius P, Gulla A, Cernauskis K, Barauskas G, Dambrauskas Z. How severe is moderately severe acute pancreatitis? Clinical validation of revised 2012 Atlanta Classification. World J Gastroenterol . 2017;23(43):7785-90.

109. Lakhey PJ, Bhandari RS, Kafle B, Singh KP, Khakurel M. Validation of ‘Moderately Severe Acute Pancreatitis’ in patients with Acute Pancreatitis. JNMA J Nepal Med Assoc. 2013;52:580-5.
-110110. Gluszek S, Kozie D. Prevalence and progression of acute pancreatitis in the świętokrzyskie voivodeship population. Pol Przegl Chir . 2012;84:618-25..

TABLE 2
List of studies that compared the efficiency of prognostic markers (chemical / biological / clinical parameter) and of old rating scores to the new concepts used to determine the severity of patients, which were disclosed after the Atlanta classification revision.

TABLE 3
Studies that just evaluated and validated the recommendations and concepts presented after the Atlanta Classification revision.

Based on TABLES 1, 2 and 3, 68.5% (61/89) of the studies applied the recommendations disclosed after the Atlanta Classification revision. Most studies that have applied the recommendations after the Atlanta Classification revision were North-American (16.4% = 10/61) and Chinese (14.7% = 9/61) (Figure 2). On the other hand, most studies that have compared prognostic factors to rating scores in order to evaluate the new recommendations were Chinese (41.2% = 7/17), and they were followed by North-American studies (11.8% = 2/17).

FIGURE 2
Studies that applied the recommendations of the Classification after the Atlanta revision, according to publication country.

DISCUSSION

Most studies (68.5% = 61/89) adhered to and applied the new recommendations published after the Atlanta Classification revision to their sampling. The main aim of more than half of these studies (55.7% = 34/61) was to evaluate the clinical evolution of patients based on the application of the new severity classification proposal (mild, moderately severe and severe). The remaining studies (44.2% = 27/61) used these recommendations to divide their sample; they took the severity classification as standard and, later, they investigated other factors capable of determining the prognosis of patients. In fact, these studies stood out, mainly because they presented and reinforced the reliability of the severity classification published after the Atlanta revision. Publications from countries located in continents such as Africa and Oceania were not identified. Latin America also presented few studies; Brazil (3.3% = 2/61) and Mexico (4.9% = 3/61) were the only Latin American countries presenting studies about this topic. In addition, although no European country has individually played a significant role in the number of publications, the analysis of the whole set of publications enabled seeing that Poland (6.6% = 4/61), Croatia (4.9% = 3/61) and Finland (4.9% = 3/61) have made considerable contributions to understand the natural clinical evolution of patients which severity was determined by the revised Atlanta classification. Despite the Chinese and American leadership in the number of publications, one should take into consideration a possible numerical overestimation bias due to their great economic and demographic power112112. United Nations Development Programme - UNDP. 2018. 2018 Statistical Update: Human Development Indices and Indicators. New York. Available from: http://http://hdr.undp.org/en/content/human-development-indices-indicators-2018-statistical-update.
http://http://hdr.undp.org/en/content/hu...
. (Figure 2)

China (41.2% = 7/17) and the United States (11.8% = 2/17) also recorded the largest number of publications among studies that just compared the efficiency of prognostic markers (C-reactive protein, hematocrit, red cell distribution width - RDW, serum calcium, thrombin-antithrombin III complex, brain natriuretic peptide - BNP, procalcitonin, apolipoprotein B, pentraxin 3 -PTX3, growth differentiation factor 15 - GDF-15, urea and body mass index) and of old rating scores (Ranson, Apache II, BISAP, PANC 3, DBC) to the new concepts aimed at determining the severity of patients with acute pancreatitis, which were released after the Atlanta classification revision (Table 2)1616. Deng LH, Hu C, Cai WH, Chen WW, Zhang XX, Shi N, et al. Plasma cytokines can help to identify the development of severe acute pancreatitis on admission. Medicine (Baltimore). 2017;96:e7312.,3838. Shen X, Sun J, Ke L, Zou L, Li B, Tong Z, Li W, Li N, Li J. Reduced lymphocyte count as an early marker for predicting infected pancreatic necrosis. BMC Gastroenterol. 2015;15:147.,4141. Kim BG, Noh MH, Ryu CH, Nam HS, Woo SM, Ryu SH, et al. A comparison of the BISAP score and serum procalcitonin for predicting the severity of acute pancreatitis. Korean J Intern Med. 2013;28:322‐9.,6060. Nikkola A, Aittoniemi J, Huttunen R, Rajala L, Nordback I, Sand J, et al. Plasma Level of Soluble Urokinase-type Plasminogen Activator Receptor Predicts the Severity of Acute Alcohol Pancreatitis. Pancreas. 2017;46:77‐82.,6767. Losurdo G, Iannone A, Principi M, Barone M, Ranaldo N, Ierardi E, et al. European Journal of Internal Medicine Acute pancreatitis in elderly patients: A retrospective evaluation at hospital admission. Eur J Intern Med . 2016;30:88-93.,8787. Abdullah B, Dusak A, Kaplan I, Gümüs M. The potential role of BMI, plasma leptin, nesfatin-1 and ghrelin levels in the early detection of pancreatic necrosis and severe acute pancreatitis: A prospective cohort study. Int J Surg. 2014;12:1310-3.,9999. Ikeura T, Horibe M, Sanui M, Sasaki M, Kuwagata Y, Nishi K, Kariya S, et al. Validation of the efficacy of the prognostic factor score in the Japanese severity criteria for severe acute pancreatitis: A large multicenter study. United European Gastroenterol J . 2017;5:389-97.. However, European countries such as Spain (11.8% = 2/17) and the United Kingdom (11.8% = 2/17) recorded the most significant contributions in this group of studies, helping to enhance the knowledge about different prognostic markers and rating scores (especially the Determinant-Based Classification). Nevertheless, they did not classify the investigated patients to assess their prognosis based on the recommendations published after the Atlanta Classification revision, fact that enabled seeing a misalignment in the application of these recommendations in clinical practices.

Interestingly, the evaluation of studies aimed at just validating the recommendations issued after the Atlanta classification revision did not show any US publication, which may suggest that this country may have already incorporated the new recommendations in clinical practices associated with the management of acute pancreatitis5858. Da B, Quezada M, Shulman I, Sheibani S, Buxbaum JL. Severe Obesity Predicts Adverse Outcomes in Acute Pancreatitis. American Journal of Gastroenterology. 2015;110:S14. https://doi.org/10.1038/ajg.2015.269.
https://doi.org/https://doi.org/10.1038/...
,5959. Nieminen A, Maksimow M, Mentula P, Kyhälä L, Kylänpää L, Puolakkainen P, et al. Circulating cytokines in predicting development of severe acute pancreatitis. Crit Care. 2014;18:R104..

In addition, the intention to only classify the severity of patients (90.2% = 55/61) and, to a lesser extent, to use other concepts such as the diagnostic criteria (19.7% = 12/61) and the new definition of pancreatic necrosis (4.9% = 3/61) has prevailed even among publications that had already acknowledged the new recommendations published after the Atlanta Classification revision. However, it is worth taking into consideration and clarifying that the truth about the real application of the new concepts and recommendations released after the Atlanta Classification revision in clinical practices deserves further investigation.

Furthermore, besides the similarity methods used to classify the severity of their patients, the greatest number of studies that the main objective was supposed to compare the Determinant-Based Classification with Atlanta revised Classification still devalue the persistent organ failure as the main criteria to considerate the worsts prognosis of the patients with acute pancreatitis55. Yang CJ, Chen J, Phillips ARJ, Windsor JA, Petrov MS. Predictors of severe and critical acute pancreatitis: A systematic review. Dig Liver Dis. 2014;46:446-51.

6. Guo Q, Li M, Chen Y, Hu W. Pancreatology Determinant-based classification and revision of the Atlanta classification, which one should we choose to categorize acute pancreatitis? Pancreatology. 2015;1-6.

7. Chen Y, Ke L, Tong Z, Li W, Li J. Association between severity and the determinant-based classification, Atlanta 2012 and Atlanta 1992, in acute pancreatitis: a clinical retrospective study. Medicine (Baltimore). 2015;94(13):e638.

8. Kadiyala V, Suleiman SL, McNabb-Baltar J, Wu BU, Banks PA, Singh VK. The Atlanta Classification, Revised Atlanta Classification, and Determinant-Based Classification of Acute Pancreatitis: Which Is Best at Stratifying Outcomes? Pancreas. 2016;45:510‐5.

9. Bansal SS, Hodson J, Sutcliffe RS, Sutcliffe RS, Marudanayagam R, Muiesan P, et al. Performance of the revised Atlanta and determinant-based classifications for severity in acute pancreatitis. Br J Surg. 2016;103:427‐33.

10. Dellinger EP, Forsmark CE, Layer P, Layer P, Levy P, Maravi-Poma E, et al. Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg. 2012;256:875‐80.
-1111. Fernandes SR, Carvalho J, Santos P, Moura CM, Antunes T, Velosa J. Atlanta, revised Atlanta, and Determinant-based classification--application in a cohort of Portuguese patients with acute pancreatitis. Eur J Gastroenterol Hepatol. 2016;28:20‐4.. Because, even those with infected necrosis, when weren’t simultaneously affected for some persistent organ failure, had more expectation to survive, a fact which proves that infected necrosis alone isn’t formal indication for open necrosectomy. So, it’s necessary a more systematic approach, in a proper time and initiated by minimally invasive procedures as imaging guided percutaneous drainage and endoscopic techniques, until be necessary more invasive measures (video laparoscopy or even laparotomy), mainly if a more significant number of organs has failure and there isn’t clinical improvement signals9292. Xu XD, Wang ZY, Zhang LY, Ni R, Wei FX, Han W, et al. Acute Pancreatitis Classifications: Basis and Key Goals. Medicine (Baltimore). 2015;94:e2182.. In fact, the revised Atlanta Classification consider the exacerbation of comorbidities and the presence of other different local complications than pancreatic and/or peripancreatic necrosis (as acute liquid collection and pseudocysts) significant criteria to classify patients as moderately severe (instead of only mild, as it would be in the Determinant-Based Criteria if the patient wasn’t with organ failure). Moreover, the Atlanta Classification identifies organ failure in a simple form (based on the modified Marshall Classification), establishing a more accurate classification of the patients with acute pancreatitis than the DBC, which leads to a more suitable method to select patients, specific for those who are included in medical researchs55. Yang CJ, Chen J, Phillips ARJ, Windsor JA, Petrov MS. Predictors of severe and critical acute pancreatitis: A systematic review. Dig Liver Dis. 2014;46:446-51.

6. Guo Q, Li M, Chen Y, Hu W. Pancreatology Determinant-based classification and revision of the Atlanta classification, which one should we choose to categorize acute pancreatitis? Pancreatology. 2015;1-6.

7. Chen Y, Ke L, Tong Z, Li W, Li J. Association between severity and the determinant-based classification, Atlanta 2012 and Atlanta 1992, in acute pancreatitis: a clinical retrospective study. Medicine (Baltimore). 2015;94(13):e638.

8. Kadiyala V, Suleiman SL, McNabb-Baltar J, Wu BU, Banks PA, Singh VK. The Atlanta Classification, Revised Atlanta Classification, and Determinant-Based Classification of Acute Pancreatitis: Which Is Best at Stratifying Outcomes? Pancreas. 2016;45:510‐5.

9. Bansal SS, Hodson J, Sutcliffe RS, Sutcliffe RS, Marudanayagam R, Muiesan P, et al. Performance of the revised Atlanta and determinant-based classifications for severity in acute pancreatitis. Br J Surg. 2016;103:427‐33.

10. Dellinger EP, Forsmark CE, Layer P, Layer P, Levy P, Maravi-Poma E, et al. Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg. 2012;256:875‐80.
-1111. Fernandes SR, Carvalho J, Santos P, Moura CM, Antunes T, Velosa J. Atlanta, revised Atlanta, and Determinant-based classification--application in a cohort of Portuguese patients with acute pancreatitis. Eur J Gastroenterol Hepatol. 2016;28:20‐4..

It is essential mentioning that few published studies, which adopted a different design from the randomized clinical trial, addressed the application of recommendations published after the Atlanta Classification revision in clinical practices. Among them, it is necessary highlighting the study by Staubli et al., who interviewed 233 physicians, who were heads of surgical or internal departments of 85 hospitals (public and private) in Switzerland, based on an online questionnaire, or on telephone conversations, about the management of patients with acute pancreatitis111111. Staubli SM, Oertli D, Nebiker CA. Assessing the severity of acute pancreatitis (ASAP) in Switzerland: a nationwide survey on severity assessment in daily clinical practice. Pancreatology. 2017;7:356-63.. The aforementioned study has shown that most physicians assessed the severity of patients with acute pancreatitis based on Ranson (87%) or APACHE II (23%) scores; few of them used the classification established and disclosed after the Atlanta revision (12%)111111. Staubli SM, Oertli D, Nebiker CA. Assessing the severity of acute pancreatitis (ASAP) in Switzerland: a nationwide survey on severity assessment in daily clinical practice. Pancreatology. 2017;7:356-63.. Assumingly, the scenario presented in the study published in 2017 by Staubli et al. reinforces the current lack of theoretical knowledge by medical professionals on the subject, as well as a possible outdated teaching process currently in progress in medical schools111111. Staubli SM, Oertli D, Nebiker CA. Assessing the severity of acute pancreatitis (ASAP) in Switzerland: a nationwide survey on severity assessment in daily clinical practice. Pancreatology. 2017;7:356-63..

CONCLUSION

Unfortunately, changes in the management of patients with acute pancreatitis may need to be taken into consideration, from the teaching process of future physicians to the updating the professionals who are currently dealing with these patients. This assumption is reinforced by the limited number of countries that reported to have started to incorporate the recommendations released after the Atlanta Classification revision in their clinical practice. This is a worrisome situation, since the incorporation of these recommendations, mainly of those associated with the new proposal to classify the severity of patients with acute pancreatitis could considerably facilitate the communication between health professionals, as well as have a directly association with the hospitalization time, mortality rates, ICU admission, need of interventions, nutritional support and longer hospital stay, mainly of patients facing the most severe conditions1111. Fernandes SR, Carvalho J, Santos P, Moura CM, Antunes T, Velosa J. Atlanta, revised Atlanta, and Determinant-based classification--application in a cohort of Portuguese patients with acute pancreatitis. Eur J Gastroenterol Hepatol. 2016;28:20‐4.. Finally, the disclosure of the current systematic review could encourage the outspread of the new recommendations in order to enable a larger number of nations to perceive, as soon as possible, the importance of updating and changing the herein presented scenario.

REFERENCES

  • 1
    Forsmark Chris E, Timothy B. Gardner, eds. Prediction and management of severe acute pancreatitis. Springer New York, 2015.
  • 2
    Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology. 2013;144:1252-61.
  • 3
    Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol. 2013;108:1400-15.
  • 4
    Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102-11.
  • 5
    Yang CJ, Chen J, Phillips ARJ, Windsor JA, Petrov MS. Predictors of severe and critical acute pancreatitis: A systematic review. Dig Liver Dis. 2014;46:446-51.
  • 6
    Guo Q, Li M, Chen Y, Hu W. Pancreatology Determinant-based classification and revision of the Atlanta classification, which one should we choose to categorize acute pancreatitis? Pancreatology. 2015;1-6.
  • 7
    Chen Y, Ke L, Tong Z, Li W, Li J. Association between severity and the determinant-based classification, Atlanta 2012 and Atlanta 1992, in acute pancreatitis: a clinical retrospective study. Medicine (Baltimore). 2015;94(13):e638.
  • 8
    Kadiyala V, Suleiman SL, McNabb-Baltar J, Wu BU, Banks PA, Singh VK. The Atlanta Classification, Revised Atlanta Classification, and Determinant-Based Classification of Acute Pancreatitis: Which Is Best at Stratifying Outcomes? Pancreas. 2016;45:510‐5.
  • 9
    Bansal SS, Hodson J, Sutcliffe RS, Sutcliffe RS, Marudanayagam R, Muiesan P, et al. Performance of the revised Atlanta and determinant-based classifications for severity in acute pancreatitis. Br J Surg. 2016;103:427‐33.
  • 10
    Dellinger EP, Forsmark CE, Layer P, Layer P, Levy P, Maravi-Poma E, et al. Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg. 2012;256:875‐80.
  • 11
    Fernandes SR, Carvalho J, Santos P, Moura CM, Antunes T, Velosa J. Atlanta, revised Atlanta, and Determinant-based classification--application in a cohort of Portuguese patients with acute pancreatitis. Eur J Gastroenterol Hepatol. 2016;28:20‐4.
  • 12
    Mounzer R, Langmead CJ, Wu BU, Evans AC, Bishehsari F, Muddana V, et al. Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis. Gastroenterology. 2012;142:1476-82.
  • 13
    Ferreira Ade F, Bartelega JA, Urbano HC, de Souza IK. Acute pancreatitis gravity predictive factors: which and when to use them? ABCD, Arq Bras Cir Dig. 2015;28:207-11.
  • 14
    Amálio SMRA, Macedo MATV, Carvalho SMMA, Moreno RP. Avaliação da mortalidade na pancreatite aguda grave: estudo comparativo entre índices de gravidade específicos e gerais. Rev Bras Ter Intensiva. 2012;24:246-51.
  • 15
    Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008;57:1698‐703.
  • 16
    Deng LH, Hu C, Cai WH, Chen WW, Zhang XX, Shi N, et al. Plasma cytokines can help to identify the development of severe acute pancreatitis on admission. Medicine (Baltimore). 2017;96:e7312.
  • 17
    Jin Z, Xu L, Wang X, Yang D. Risk Factors for Worsening of Acute Pancreatitis in Patients Admitted with Mild Acute Pancreatitis. Med Sci Monit. 2017;23:1026-32.
  • 18
    Souza GD, Souza LRQ, Cuenca RM, Jerônimo BSM, Souza GM, Vilela VM. Artigo de Revisão Entendendo o Consenso Internacional Para as Pancreatites Agudas: classificação de Atlanta 2012. Arq Bras Cir Dig. 2016;29:206-10.
  • 19
    Baker ME, Nelson RC, Rosen MP, Blake MA, Cash BD, Hindman NM, et al. ACR Appropriateness Criteria® acute pancreatitis. Ultrasound Q. 2014;30:267‐73.
  • 20
    Ashley SW, Perez A, Pierce EA, Brooks DC, Moore FD, Whang EE, Banks PA, Zinner MJ. Necrotizing pancreatitis: Contemporary Analysis of 99 Consecutive Cases. Ann Surg. 2001;234:572-9.
  • 21
    Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;6736:1-12.
  • 22
    Cunha EFC, Rocha MS, Pereira FP, Blasbalg R, Baroni RH. Necrose pancreática delimitada e outros conceitos atuais na avaliação radiológica da pancreatite aguda. Radiol Bras. 2014;47:165-75.
  • 23
    Sheu Y, Furlan A, Almusa O, Papachristou G, Bae KT. The revised Atlanta classification for acute pancreatitis: a CT imaging guide for radiologists. Emerg Radiol. 2012;19:237-43.
  • 24
    Ribeiro G, Silva G, Martins M, Bogea E, Cantanhede J, Abreu J. Etiologia E Mortalidade Por Pancreatite Aguda: Uma Revisão Sistemática. Arquivos Catarinenses de Medicina. 2017;46:168-81.
  • 25
    Tércio DC, José P, Edivaldo U, Samir R. A Brazilian survey regarding the management of acute pancreatitis. Revista do Colégio Brasileiro de Cirurgiões, 2008. p. 304-10.
  • 26
    Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62:1006‐12.
  • 27
    Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration, 2011.
  • 28
    Schmidt K, Büning J, Weitz G, Woitalla J, Wellh P, Fellermann K. Detrimental effect of high volume fluid administration in acute pancreatitis e A retrospective analysis of 391 patients. Pancreatology. 2014;14:478-83.
  • 29
    Karabulut U, Koyuncu MB, Sezgin O, Ucbilek E, Aydin MK, Altintas E. Mo1327 Early Oral Feeding and Selection of Initial Diet in Mild Acute Pancreatitis. Gastroenterology. 2014;146(5):S-621.
  • 30
    Beduschi MG, Mello AL, VON-Mühlen B, Franzon O. The panc 3 score predicting severity of acute pancreatitis. Arq Bras Cir Dig . 2016;29:5-8.
  • 31
    Sun Y, Lu Z, Zhang X, Geng X, Cao L, Yin L. Pancreatology. The effects of fluid resuscitation according to PiCCO on the early stage of severe acute pancreatitis. Pancreatology. 2015.
  • 32
    Zhu Y, Pan X, Zeng H, Xia L, Liu P, Lv N. A Study on the Etiology, Severity, and Mortality of 3260 Patients With Acute Pancreatitis According to the Revised Atlanta Classification in Jiangxi, China Over an 8-Year Period. Pancreas, 2017;46:504-9.
  • 33
    Zeng Y, Zhang W, Lu Y, Huang C, Wang X. Impact of hypertriglyceridemia on the outcome of acute biliary pancreatitis. Am J Med Sci. 2014;348:399‐402.
  • 34
    Li G, Wang X, Shen X, Ke L, Li W, Tong Z, Zhou J. Positive end-expiratory pressure setting guided by esophageal pressure in patients with intra-abdominal hypertension: a prosp ective, randomized, open-label trial; Pancreatology, 2016;16:S25.
  • 35
    Lin S, Hong W, Basharat Z, Wang Q, Pan J, Zhou M. Blood Urea Nitrogen as a Predictor of Severe Acute Pancreatitis Based on the Revised Atlanta Criteria: Timing of Measurement and Cutoff Points. 2017;2017.
  • 36
    Qi X, Yang F, Huang H, Du Y, Chen Y, Wang M, et al. OPEN A reduced lymphocyte ratio as an early marker for predicting acute pancreatitis. Nat Publ Gr. 2017;(415):1-6.
  • 37
    Jia R, Tang M, Qiu L, Sun R, Cheng L, Ma X, et al. Increased interleukin-23/17 axis and C-reactive protein are associated with severity of acute pancreatitis in patients. Pancreas. 2015;44:321‐5.
  • 38
    Shen X, Sun J, Ke L, Zou L, Li B, Tong Z, Li W, Li N, Li J. Reduced lymphocyte count as an early marker for predicting infected pancreatic necrosis. BMC Gastroenterol. 2015;15:147.
  • 39
    Kim TN, Kim SB, Cho JH, Kim KH. Comparison of clinical course and outcome of acute pancreatitis according to two main etiologies: alcohol vs. gallstone. Pancreatology. 2009;14(3):S62.
  • 40
    Huh JH, Jung S, Cho SK, Lee KJ, Kim JW. Predictive value of apolipoprotein B and A-I ratio in severe acute pancreatitis. J Gastroenterol Hepatol. 2018;33:548-53.
  • 41
    Kim BG, Noh MH, Ryu CH, Nam HS, Woo SM, Ryu SH, et al. A comparison of the BISAP score and serum procalcitonin for predicting the severity of acute pancreatitis. Korean J Intern Med. 2013;28:322‐9.
  • 42
    Kim J, Cho JH, Kim EJ, Kim Y, Kim HM, Kim Y. Mo1253 - Risk Factors of Recurrent Acute Pancreatitis and Progression to Chronic Pancreatitis after the first Attack of Acute Pancreatitis. Gastroenterology. 2018;154:S-721-S-722.
  • 43
    Mikolasevic I, Orlic L, Poropat G, Jakopcic I, Stimac D, Klanac A, et al. European Journal of Internal Medicine Nonalcoholic fatty liver and the severity of acute pancreatitis. Eur J Intern Med. 2017 Mar;38:73-78.
  • 44
    Mikolasevic I, Milic S, Orlic L, Poropat G, Jakopcic I, Franjic N, et al. Metabolic syndrome and acute pancreatitis. Eur J Intern Med . 2016
  • 45
    Trgo G, Zaja I, Bogut A, Kovacic V, Meter I, Vucic LM, et al. Association of Asymmetric Dimethylarginine With Acute Pancreatitis-Induced Hyperglycemia. Pancreas. 2016;45:694-99.
  • 46
    Vujasinovic M, Tepes B, Makuc J, Rudolf S, Zaletel J, Vidmar T, et al. Pancreatic exocrine insufficiency, diabetes mellitus and serum nutritional markers after acute pancreatitis. World J Gastroenterol. 2014;20(48):18432‐8.
  • 47
    Pintado M, Trascasa M, Arenillas C, Ortiz Y, Zárate D, Pardo A, et al. European Journal of Internal Medicine. New Atlanta Classification of acute pancreatitis in intensive care unit: Complications and prognosis. Eur J Intern Med . 2016;30:82-87.
  • 48
    Bozhychko M, Cárdenas-Jaén K, Ruiz-Rebollo ML, de Madaria E. Use of statins and nonsteroidal anti-inflammatory drugs and severity of acute pancreatitis. Pancreatology, 2017. 17(5), S12.
  • 49
    Ellery KM, Ms DO, Kumar S, Mmm WC, Gariepy C. The Benefits of Early Oral Nutrition in Mild Acute Pancreatitis. J Pediatr. 2017;1-6.
  • 50
    Sugimoto M, Sonntag DP, Flint GS, Boyce CJ, Kirkham JC, Harris TJ, et al. A percutaneous drainage protocol for severe and moderately severe acute pancreatitis. Surg Endosc. 2015;29:3282‐91.
  • 51
    Gougol A, Dugum M, Dudekula A, Greer P, Slivka A, Whitcomb DC, et al. Clinical outcomes of isolated renal failure compared to other forms of organ failure in patients with severe acute pancreatitis. World J Gastroenterol . 2017;23:5431‐7.
  • 52
    Vipperla K, Somerville C, Furlan A, Koutroumpakis E, Saul M, Chennat J, et al. Clinical Profile and Natural Course in a Large Cohort of Patients With Hypertriglyceridemia and Pancreatitis. J Clin Gastroenterol. 2017;51:77‐85.
  • 53
    Vlada AC, Schmit B, Perry A, Trevino JG, Behrns KE, Hughes SJ. Failure to follow evidence-based best practice guidelines in the treatment of severe acute pancreatitis. HPB (Oxford). 2013;822-7.
  • 54
    Buxbaum JL, Quezada M, Da B, Jani N, Lane C, Mwengela D, et al. Early Aggressive Hydration Hastens Clinical Improvement in Mild Acute Pancreatitis. Am J Gastroenterol . 2017;112:797‐803.
  • 55
    Buxbaum JL, Da B, Quezada M, Jani N, Mwengela D, Thomas E, et al. S-64 AGA Abstracts. Gastroenterology. 2016;150:S64-5.
  • 56
    Dimagno MJ, Wamsteker E, Rizk RS, Spaete JP, Gupta S, Sahay T, et al. A Combined Paging Alert and Web-Based Instrument Alters Clinician Behavior and Pancreatitis. Am J Gastroenterol . 2014;109:306-15.
  • 57
    Bishu S, Koutroumpakis E, Mounzer R, Stello K, Pollock N, Evans A, Papachristou G. The-251 A/T Polymorphism in the IL8 Promoter is a Risk Factor for Acute Pancreatitis. Pancreas. 2018;47:87-91.
  • 58
    Da B, Quezada M, Shulman I, Sheibani S, Buxbaum JL. Severe Obesity Predicts Adverse Outcomes in Acute Pancreatitis. American Journal of Gastroenterology. 2015;110:S14. https://doi.org/10.1038/ajg.2015.269.
    » https://doi.org/https://doi.org/10.1038/ajg.2015.269
  • 59
    Nieminen A, Maksimow M, Mentula P, Kyhälä L, Kylänpää L, Puolakkainen P, et al. Circulating cytokines in predicting development of severe acute pancreatitis. Crit Care. 2014;18:R104.
  • 60
    Nikkola A, Aittoniemi J, Huttunen R, Rajala L, Nordback I, Sand J, et al. Plasma Level of Soluble Urokinase-type Plasminogen Activator Receptor Predicts the Severity of Acute Alcohol Pancreatitis. Pancreas. 2017;46:77‐82.
  • 61
    Nukarinen E, Lindström O, Kuuliala K, Kylänpää L, Pettilä V, Puolakkainen P, et al. Association of Matrix Metalloproteinases -7, -8 and -9 and TIMP -1 with Disease Severity in Acute Pancreatitis. A Cohort Study. PLoS One. 2016;11:e0161480.
  • 62
    Bakker OJ, van Santvoort H, Besselink MG, Boermeester MA, van Eijck C, Dejong K, et al. Extrapancreatic necrosis without pancreatic parenchymal necrosis: a separate entity in necrotising pancreatitis? Gut. 2013;62:1475‐80.
  • 63
    Párniczky A, Mosztbacher D, Zsoldos F, Tóth A, Lásztity N, Hegyi P, et al. Analysis of Pediatric Pancreatitis (APPLE Trial): Pre-Study Protocol of a Multinational Prospective Clinical Trial. Digestion. 2016;93:105‐10.
  • 64
    Doley RP, Yadav TD, Wig JD, Kochhar R, Singh G, Bharathy KG, et al. Enteral nutrition in severe acute pancreatitis. JOP. 2009;10:157‐62.
  • 65
    John BJ, Sambandam S, Garg P, Singh G, Kaur M, Baskaran R, et al. Persistent Systemic Inflammatory Response Syndrome predicts the need for tertiary care in Acute Pancreatitis. Acta Gastroenterol Belg. 2017;80:377‐80.
  • 66
    Stirling AD, Moran NR, Kelly ME, Ridgway PF, Conlon KC. The predictive value of C-reactive protein (CRP) in acute pancreatitis - is interval change in CRP an additional indicator of severity? HPB (Oxford). 2017;19:874-80.
  • 67
    Losurdo G, Iannone A, Principi M, Barone M, Ranaldo N, Ierardi E, et al. European Journal of Internal Medicine Acute pancreatitis in elderly patients: A retrospective evaluation at hospital admission. Eur J Intern Med . 2016;30:88-93.
  • 68
    Sugawara S, Arai Y, Sone M, Katai H. Frequency, severity, and risk factors for acute pancreatitis after percutaneous transhepatic biliary stent placement across the papilla of vater. Cardiovasc Intervent Radiol. 2017;40:1904-10.
  • 69
    Karpavicius A, Dambrauskas Z, Gradauskas A, Samuilis A, Zviniene K, Kupcinskas J, et al. The clinical value of adipokines in predicting the severity and outcome of acute pancreatitis. BMC Gastroenterol . 2016;16:99.
  • 70
    Chacón-portillo MA, Payró-ramírez G, Peláez-luna MC, Uscanga-domínguez LF, Vasquéz-ortiz Z, Orihuela C, et al. Abnormal Cardiovascular Findings in Acute Pancreatitis: Are They Associated with Disease Severity ? Rev Inves Clin. 2017;314-8.
  • 71
    Riquelme F, Marinkovic B, Salazar M, Martínez W, Catan F, Uribe-Echevarría S, et al. Early laparoscopic cholecystectomy reduces hospital stay in mild gallstone pancreatitis. A randomized controlled trial. HPB (Oxford). 2020;22:26‐33.
  • 72
    Cuellar-Monterrubio JE, Robles RM, Gonzalez-Moreno EI, Borjas-Almaguer OD, Garcia-Compean D, Maldonado Garza HJ, González-González JA. Guidelines Versus Directed IV Fluid Therapy in Acute Pancreatitis of More than 24 Hours of Clinical Evolution: A Prospective Randomized Clinical Trial Gastroenterology. Gastroenterology 2017;152(5):S281. DOI: 10.1016/S0016-5085(17)31235-0.
    » https://doi.org/10.1016/S0016-5085(17)31235-0
  • 73
    Głuszek S, Nawacki Ł, Matykiewicz J, Kot M, Kuchinka J. Severe Vascular Complications Of Acute Pancreatitis. Pol Przegl Chir. 2015;87:485‐90.
  • 74
    Madaria E, Herrera-Marante I, Gonzalez-Camacho V, Bonjoch L, Quesada-Vazquez N, Almenta-Saavedra I, et al. Fluid resuscitation with lactated Ringer’s solution vs normal saline in acute pancreatitis: A triple-blind, randomized, controlled trial. HPB (Oxford). 2018;6:63-72.
  • 75
    Kuśnierz-Cabala B, Gala-Błądzińska A, Mazur-Laskowska M, Dumnicka P, Sporek M, Matuszyk A, et al. Serum Uromodulin Levels in Prediction of Acute Kidney Injury in the Early Phase of Acute Pancreatitis. Molecules. 2017;22:988.
  • 76
    Sporek M, Dumnicka P, Gala-Błądzińska A, Małgorzata Mazur-Laskowska, Walocha J, Ceranowicz P, et al. Determination of serum neutrophil gelatinase-associated lipocalin at the early stage of acute pancreatitis. Folia Med Cracov. 2016;56:5‐16.
  • 77
    Huggett MT, Oppong KW, Pereira SP, Keane MG, Mitra V, Charnley RM, Nayar MK. Endoscopic drainage of walled-off pancreatic necrosis using a novel self-expanding metal stent. Endoscopy. 2015;47:929‐32.
  • 78
    Suppiah A, Malde D, Arab T, Hamed M, Allgar V, Smith AM, Morris-Stiff G. The prognostic value of the neutrophil-lymphocyte ratio (NLR) in acute pancreatitis: identification of an optimal NLR. J Gastrointest Surg. 2013;17:675‐81.
  • 79
    Haffar S, Bazerbachi F, Prokop L, Watt KD, Murad MH, Chari ST. Frequency and prognosis of acute pancreatitis associated with fulminant or non-fulminant acute hepatitis A: A systematic review. Pancreatology. 2017;17:166-75.
  • 80
    Bertilsson S, Swärd P, Kalaitzakis E. Factors That Affect Disease Progression After First Attack of Acute Pancreatitis. Clin Gastroenterol Hepatol. 2015;13:1662-9.e3.
  • 81
    Ragnarsson T, Andersson R, Ansari D, Persson U, Andersson B. Acute biliary pancreatitis: focus on recurrence rate and costs when current guidelines are not complied. Scand J Gastroenterol. 2017;52:264‐9.
  • 82
    Shen HN, Chang YH, Chen HF, Lu CL, Li CY. Increased risk of severe acute pancreatitis in patients with diabetes. Diabet Med. 2012;29:1419‐24.
  • 83
    İnce AT, Senturk H, Singh VK, Yildiz K, Danalioğlu A, Çinar A, et al. A randomized controlled trial of home monitoring versus hospitalization for mild non-alcoholic acute interstitial pancreatitis: A pilot study. Pancreatology. 2014;14:174-8.
  • 84
    de-Madaria E, Herrera-Marante I, González-Camacho V, Bonjoch L, Quesada-Vázquez N, Almenta-Saavedra I, et al. Fluid resuscitation with lactated Ringer’s solution vs normal saline in acute pancreatitis: A triple-blind, randomized, controlled trial. United European Gastroenterol J. 2018;6:63-72.
  • 85
    Tozlu M, Kayar Y, İnce AT, Baysal B, Şentürk H. Low molecular weight heparin treatment of acute moderate and severe pancreatitis: A randomized, controlled open-label study. Turk J Gastroenterol. 2019;30:81‐7.
  • 86
    Fidan S, Erkut M, Cosar AM, Yogun Y, Örem A, Sönmez M, Arslan M. Higher Thrombin-Antithrombin III Complex Levels May Indicate Severe Acute Pancreatitis. Dig Dis. 2018;36:244‐51.
  • 87
    Abdullah B, Dusak A, Kaplan I, Gümüs M. The potential role of BMI, plasma leptin, nesfatin-1 and ghrelin levels in the early detection of pancreatic necrosis and severe acute pancreatitis: A prospective cohort study. Int J Surg. 2014;12:1310-3.
  • 88
    Koziel D, Gluszek S, Matykiewicz J, Lewitowicz P, Drozdzak Z. Comparative analysis of selected scales to assess prognosis in acute pancreatitis. Can J Gastroenterol Hepatol . 2015;29:299-303.
  • 89
    Liu J, Cao F, Dong XM, Yu Li P, Li HC, Qi BJ, Li F. Early prediction of organ failure under the revised Atlanta classification. Turk J Gastroenterol . 2017;28:46‐52.
  • 90
    He WH, Zhu Y, Zhu Y, Jin Q, Xu HR, Xion ZJ, et al. Comparison of multifactor scoring systems and single serum markers for the early prediction of the severity of acute pancreatitis. J Gastroenterol Hepatol . 2017;32:1895‐901.
  • 91
    Zhang J, Shahbaz M, Fang R, Liang B, Gao C, Gao H, et al. Comparison of the BISAP scores for predicting the severity of acute pancreatitis in Chinese patients according to the latest Atlanta classification. J Hepatobiliary Pancreat Sci. 2014;21:689‐94.
  • 92
    Xu XD, Wang ZY, Zhang LY, Ni R, Wei FX, Han W, et al. Acute Pancreatitis Classifications: Basis and Key Goals. Medicine (Baltimore). 2015;94:e2182.
  • 93
    Yang Z, Dong L, Zhang Y, Yang C, Gou S, Li Y, et al. Prediction of Severe Acute Pancreatitis Using a Decision Tree Model Based on the Revised Atlanta Classification of Acute Pancreatitis. PLoS One. 2015;10:e0143486.
  • 94
    Lee KJ, Kim HM, Choi JS, Kim YJ, Kim YS, Cho JH. Comparison of Predictive Systems in Severe Acute Pancreatitis According to the Revised Atlanta Classification. Pancreas. 2016;45:46‐50.
  • 95
    Zubia-Olaskoaga F, Maraví-Poma E, Urreta-Barallobre I, Ramírez-Puerta MR, Mourelo-Fariña M, Marcos-Neira MP, et al. Comparison Between Revised Atlanta Classification and Determinant-Based Classification for Acute Pancreatitis in Intensive Care Medicine. Why Do Not Use a Modified Determinant-Based Classification? Crit Care Med. 2016;44:910‐7.
  • 96
    Acevedo-Piedra NG, Moya-Hoyo N, Rey-Riveiro M, Gil S, Laura S, Juan M, et al. Validation of the determinant-based classification and revision of the Atlanta classification systems for acute pancreatitis. Clin Gastroenterol Hepatol . 2014;12:311‐6.
  • 97
    Nawaz H, Mounzer R, Yadav D, Yabes JG, Slivka A. Revised Atlanta and Determinant-Based Classifi cation : Application in a Prospective Cohort of Acute Pancreatitis Patients. Am J Gastroenterol [Internet]. 2013;108:1911-7.
  • 98
    Jones MJ, Neal CP, Ngu WS, Dennison AR, Garcea G. Early warning score independently predicts adverse outcome and mortality in patients with acute pancreatitis. Langenbecks Arch Surg. 2017;402:811-9.
  • 99
    Ikeura T, Horibe M, Sanui M, Sasaki M, Kuwagata Y, Nishi K, Kariya S, et al. Validation of the efficacy of the prognostic factor score in the Japanese severity criteria for severe acute pancreatitis: A large multicenter study. United European Gastroenterol J . 2017;5:389-97.
  • 100
    Gravito-Soares M, Gravito-Soares E, Gomes D, Almeida N, Tomé L. Red cell distribution width and red cell distribution width to total serum calcium ratio as major predictors of severity and mortality in acute pancreatitis. BMC Gastroenterol . 2018;18:108.
  • 101
    Chen C, Huang Z, Li H, Song B, Yuan F. Evaluation of extrapancreatic inflammation on abdominal computed tomography as an early predictor of organ failure in acute pancreatitis as defined by the revised Atlanta classification. Medicine (Baltimore). 2017;96(15).
  • 102
    Huang J, Qu H, Zheng Y, Song X, Li L, Xu Z. The revised Atlanta criteria 2012 altered the classification, severity assessment and management of acute pancreatitis. Hepatobiliary Pancreat Dis Int.. 2016;15:310-5.
  • 103
    Choi J, Kim M, Oh D, Hyun W, Hyun D, Soo S, et al. Clinical relevance of the revised Atlanta classification focusing on severity stratification system. Pancreatology. 2014;14:324-9.
  • 104
    Kim EJ, Cho JH, Oh KY, Kim SY, Kim YS. The Risk Factors for Moderately Severe and Severe Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis According to the Revised Atlanta Classification. Pancreas. 2017;46:1208-13.
  • 105
    Bouwense SA, van Brunschot S, van Santvoort HC, Besselink MG, Bollen TL, Bakker OJ, et al. Describing Peripancreatic Collections According to the Revised Atlanta Classification of Acute Pancreatitis: An International Interobserver Agreement Study. Pancreas. 2017;46:850‐7.
  • 106
    Talukdar R, Bhattacharrya A, Rao B, Sharma M, Reddy DN. Pancreatology Clinical utility of the Revised Atlanta Classification of acute pancreatitis in a prospective cohort: Have all loose ends been tied? Pancreatology. 2014;14:257-62.
  • 107
    Thandassery RB, Yadav TD, Dutta U, Appasani S, Singh K, Kochhar R. Prospective validation of 4-category classification of acute pancreatitis severity. Pancreas. 2013;42:392‐6.
  • 108
    Ignatavicius P, Gulla A, Cernauskis K, Barauskas G, Dambrauskas Z. How severe is moderately severe acute pancreatitis? Clinical validation of revised 2012 Atlanta Classification. World J Gastroenterol . 2017;23(43):7785-90.
  • 109
    Lakhey PJ, Bhandari RS, Kafle B, Singh KP, Khakurel M. Validation of ‘Moderately Severe Acute Pancreatitis’ in patients with Acute Pancreatitis. JNMA J Nepal Med Assoc. 2013;52:580-5.
  • 110
    Gluszek S, Kozie D. Prevalence and progression of acute pancreatitis in the świętokrzyskie voivodeship population. Pol Przegl Chir . 2012;84:618-25.
  • 111
    Staubli SM, Oertli D, Nebiker CA. Assessing the severity of acute pancreatitis (ASAP) in Switzerland: a nationwide survey on severity assessment in daily clinical practice. Pancreatology. 2017;7:356-63.
  • 112
    United Nations Development Programme - UNDP. 2018. 2018 Statistical Update: Human Development Indices and Indicators. New York. Available from: http://http://hdr.undp.org/en/content/human-development-indices-indicators-2018-statistical-update
    » http://http://hdr.undp.org/en/content/human-development-indices-indicators-2018-statistical-update

  • Disclosure of funding: no funding received

Publication Dates

  • Publication in this collection
    23 Apr 2021
  • Date of issue
    Jan-Mar 2021

History

  • Received
    18 June 2020
  • Accepted
    21 Oct 2020
Instituto Brasileiro de Estudos e Pesquisas de Gastroenterologia e Outras Especialidades - IBEPEGE. Rua Dr. Seng, 320, 01331-020 São Paulo - SP Brasil, Tel./Fax: +55 11 3147-6227 - São Paulo - SP - Brazil
E-mail: secretariaarqgastr@hospitaligesp.com.br