Accumulating evidence underlines the relationship between sepsis, systemic multiorgan damage (lung, liver, kidney, and heart) and elevated serum and peritoneal concentrations of cytokines (IL-1, IL-6, IL-8, IL-10) and tumor necrosis factor (TNF) [3–12]. A procedure known to reduce plasma cytokine BIRB 796 in vivo levels is continuous venovenous
diahemofiltration (CVVDH) [13, 14]. As well as purifying the blood, hemofiltration has a major adjunctive therapeutic role as immunomodulatory therapy in sepsis [15, 16]. The high levels of inflammatory mediators (cytokines and others) found not only in serum but also in peritoneal fluid from patients with SAP underline the importance of reducing cytokine levels in the SAP-related systemic inflammatory response syndrome (SIRS) [2, 17, 18]. In 20-30% of patients manifestingprogressive Volasertib price multiorgan failure, intensive care treatment fails and mortality reaches 40% . In these critically ill patients, severe complications
such as abdominal compartment syndrome or sepsis often necessitate emergency laparotomy [20, 21]. Prompted by reports underlining the importance of reducing circulating inflammatory mediators in severe acute pancreatitis [3, 22–28], we conjectured that peritoneal and systemic cytokine concentrations could be reduced by combining emergency laparotomy with continuous perioperative peritoneal lavage with postoperative CVVDH. Lowering local and systemic cytokine toxicity might thus reduce morbidity and mortality in acute pancreatitis. Our aim in this preliminary single-center study was to find out whether in a small series of selected critically ill patients with SAP CBL-0137 price refractory to ICU therapy a new approach comprising emergency laparotomy to resolve abdominal compartment syndrome or sepsis followed by continuous perioperative peritoneal lavage to remove local cytokines and postoperative
CVVDH to reduce systemic cytokines would benefit patients’ outcome. As outcome variables we evaluated postoperative IL-6 and TNF concentrations in serum, peritoneal lavage Cyclooxygenase (COX) outflow and CVVDH filtrate and sought an association between their decrease and changes in the clinical progression of SAP over time as measured by APACHE II scores. Methods We studied 23 consecutive patients with acute pancreatitis diagnosed according to the Italian Association for the Study of the Pancreas (AISP) criteria . The severity of acute pancreatitis was classified according to the Atlanta criteria . The major cause of acute pancreatitis was biliary disease (20 patients) followed by alcohol (2 patients) and hyperlipidemia (1 patient). Of the 23 patients enrolled, 18 had mild acute pancreatitis but 5 had severe acute pancreatitis on presentation. According to the Balthazar computed tomographic (CT) criteria for grading acute pancreatitis  12 patients were in grade C, 8 in grade D and 3 in grade E (severe pancreatitis).