Clinical evaluation of the M-ANNHEIM classification: Development of the M-ANNHEIM-Surgery-Score as a new tool to monitor patients with chronic pancreatitis

Michael Hirth; Christel Weiss; Felix Rückert; Roland H. Pfützer; Torsten J. Wilhelm; Svetlana Hetjens; Philip D. Hardt; Natalia Gubergrits; Matthias P. Ebert; Alexander Schneider

doi:10.1055/a-0752-0439

Zeitschrift für Gastroenterologie, Table of Contents

Z Gastroenterol 2018; 56(12): 1481-1490
DOI: 10.1055/a-0752-0439

Originalarbeit

Clinical evaluation of the M-ANNHEIM classification: Development of the M-ANNHEIM-Surgery-Score as a new tool to monitor patients with chronic pancreatitis

Klinische Evaluation der M-ANNHEIM Klassifikation: Entwicklung des M-ANNHEIM-Surgery-Scores als ein neues Instrument zur Überwachung von Patienten mit chronischer Pankreatitis

Michael Hirth

¹Department of Medicine II, University-Medical-Center Mannheim, Medical Faculty at Mannheim, University of Heidelberg, Mannheim, Germany

,

Christel Weiss

²Medical Statistics, University-Medical-Center Mannheim, Medical Faculty at Mannheim, University of Heidelberg, Mannheim, Germany

,

Felix Rückert

³Department of Surgery, University-Medical-Center Mannheim, Medical Faculty at Mannheim, University of Heidelberg, Mannheim, Germany

,

Roland H. Pfützer

¹Department of Medicine II, University-Medical-Center Mannheim, Medical Faculty at Mannheim, University of Heidelberg, Mannheim, Germany

,

Torsten J. Wilhelm

³Department of Surgery, University-Medical-Center Mannheim, Medical Faculty at Mannheim, University of Heidelberg, Mannheim, Germany

,

Svetlana Hetjens

²Medical Statistics, University-Medical-Center Mannheim, Medical Faculty at Mannheim, University of Heidelberg, Mannheim, Germany

,

Philip D. Hardt

⁴Department of Gastroenterology, University-Hospital Gießen, Gießen, Germany

,

Natalia Gubergrits

⁵Department of Gastroenterology, University-Hospital Donetsk, Donetsk, Ukraine

,

Matthias P. Ebert

¹Department of Medicine II, University-Medical-Center Mannheim, Medical Faculty at Mannheim, University of Heidelberg, Mannheim, Germany

,

Alexander Schneider

¹Department of Medicine II, University-Medical-Center Mannheim, Medical Faculty at Mannheim, University of Heidelberg, Mannheim, Germany

› Author Affiliations

Abstract

Objectives The M-ANNHEIM classification of chronic pancreatitis (CP) stratifies degrees of disease severity according to the M-ANNHEIM-Severity-Score. We aimed to demonstrate the clinical usefulness of the M-ANNHEIM-Severity-Score in quantifying and predicting the frequency of pancreatic surgery, and to establish the M-ANNHEIM-Surgery-Score as a simplified system for patient surveillance regarding the demand of pancreatic surgery.

Methods We performed a retrospective, cross-sectional study with 741 CP patients (Mannheim/Germany, n = 537; Gießen/Germany, n = 100; Donetsk/Ukraine, n = 104) categorized according to the M-ANNHEIM classification.

Results We observed a significantly higher M-ANNHEIM-Severity-Score in patients that were classified within 7 days preceding pancreatic surgery than in individuals that did not require surgery (p < 0.001, Mann–Whitney-U-test). Using a logistic regression analysis with all variables of the M-ANNHEIM-Severity-Score, we established the M-ANNHEIM-Surgery-Score as a simplified new tool to identify patients that may require surgery. A receiver operating characteristic-analysis revealed a cut-off-value of 9 points within the M-ANNHEIM-Surgery-Score to identify these individuals (sensitivity 78.7 %, specificity 91 %). Based on the M-ANNHEIM-Surgery-Score, we defined three categories for demand of surgery with frequencies of pancreatic operations of 1.6 % (n = 7/440) in the “Baseline-Demand”-category, 7 % (n = 12/172) in the “Low-Demand”-category (p < 0.0001, Chi-square-test, OR 4.6, Confidence Interval (CI) 1.8 – 12), and 54 % (n = 70/129) in the “High-Demand”-category (p < 0.0001, OR 73, CI 32 – 167). Patients that were categorized for the “High-Demand”-category, but were not operated on, had a significantly increased ratio of clinical features that hamper performance of surgery (p < 0.001, Chi-square-test).

Conclusions The M-ANNHEIM-Surgery-Score represents a useful tool to monitor patients with CP and to estimate the demand of surgery in CP.

Zusammenfassung

Hintergrund und Ziele Die M-ANNHEIM-Klassifikation der chronischen Pankreatitis unterscheidet verschiedene Erkrankungsaktivitäten gemäß dem M-ANNHEIM-Severity-Score. Es war das Ziel unserer Arbeit, den klinischen Nutzen des M-ANNHEIM-Severity-Score bei der Quantifizierung des Bedarfs an Pankreasoperationen und bei der Vorhersage hinsichtlich einer Operationsnotwendigkeit bei Patienten mit chronischer Pankreatitis aufzuzeigen und den M-ANNHEIM-Surgery-Score als ein vereinfachtes System zur Patientenüberwachung hinsichtlich des Operationsbedarfs zu etablieren.

Methoden Wir führten eine retrospektive Querschnittsstudie mit 741 Patienten mit chronischer Pankreatitis durch (Mannheim/Deutschland, n = 537; Gießen/Deutschland, n = 100; Donetsk/Ukraine, n = 104), die gemäß der M-ANNHEIM-Klassifikation kategorisiert waren.

Ergebnisse Wir beobachteten einen signifikant höheren M-ANNHEIM-Severity-Score bei Patienten, die innerhalb von 7 Tagen vor einer Pankreasoperation klassifiziert wurden, als bei Patienten, die nicht unmittelbar vor einer Operation standen (p < 0,001, Mann–Whitney-U-Test). Wir konnten durch eine logistische Regressionsanalyse mit allen Variablen des M-ANNHEIM-Severity-Score den M-ANNHEIM-Surgery-Score als ein vereinfachtes und neues Werkzeug etablieren, das zur Identifikation von Patienten beiträgt, die möglicherweise eine Pankreasoperation benötigen. Eine Receiver-Operator-Characteristic-Analyse ergab einen Cut-Off-Wert von 9 Punkten im M-ANNHEIM-Surgery-Score, der diese Patienten identifiziert (Sensitivität 78,7 %, Spezifität 91 %). Mit dem M-ANNHEIM-Surgery-Score konnten 3 Kategorien des Bedarfs einer Pankreasoperation abgegrenzt werden: Die „Basisbedarfskategorie“ mit einer Häufigkeit von Pankreasoperationen von 1,6 % (n = 7/440), die „Niedrigbedarfskategorie“ mit einer Häufigkeit von Pankreasoperationen von 7 % (n = 12/172; p < 0,0001, Chi-Square-Test, OR 4,6, Konfidenzintervall (CI) 1,8 – 12) und die „Hochbedarfskategorie“ mit einer Häufigkeit von Pankreasoperationen von 54 % (n = 70/129; p < 0,0001, OR 73, CI 32 – 167). Patienten, die in der „Hochbedarfskategorie“ lagen, die aber nicht operiert wurden, hatten signifikant häufiger klinische Merkmale, die die Durchführung einer Pankreasoperation behinderten (p < 0,001, Chi-Square-Test).

Schlussfolgerung Der M-ANNHEIM-Surgery-Score stellt ein nützliches Werkzeug zur Überwachung von Patienten mit chronischer Pankreatitis dar und unterstützt die Einschätzung des Bedarfs einer Pankreasoperation in diesem Patientenkollektiv.

Key words

chronic pancreatitis - classification - pancreatic surgery - pancreatic imaging

Schlüsselwörter

Chronische Pankreatitis - Klassifikation - Pankreasoperation - Pankreasbildgebung

Full Text

References

References
1 Layer P, Yamamoto H, Kalthoff L. et al. The different courses of early and late onset idiopathic and alcoholic chronic pancreatitis. Gastroenterology 1994; 107: 1481-1487
2 Witt H, Apte MV, Keim V. et al. Chronic pancreatitis: challenges and advances in pathogenesis, genetics, diagnosis, and therapy. Gastroenterology 2007; 132: 1557-1573
3 Majumder S, Chari ST. Chronic pancreatitis. Lancet 2016; 387: 1957-1966
4 Ammann RW, Heitz PU, Klöppel G. Course of alcoholic chronic pancreatitis: a prospective clinicomorphological long-term study. Gastroenterology 1996; 111: 224-231
5 Ammann RW, Muellhaupt B. The natural history of pain in alcoholic chronic pancreatitis. Gastroenterology 1999; 116: 1132-1140
6 Ahmed Ali U, Nieuwenhuijs VB, van Eijck CH. et al. Clinical outcome in relation to timing of surgery in chronic pancreatitis: a nomogram to predict pain relief. Arch Surg 2012; 147: 925-932
7 Yang CJ, Bliss LA, Freedman SD. et al. Surgery for chronic pancreatitis: the role of early surgery in pain management. Pancreas 2015; 44: 819-823
8 Yang CJ, Bliss LA, Schapira EF. et al. Systematic review of early surgery for chronic pancreatitis: impact on pain, pancreatic function, and re-intervention. J Gastrointest Surg 2014; 18: 1863-1869
9 Büchler MW, Martignoni ME, Friess H. et al. A proposal for a new clinical classification of chronic pancreatitis. BMC Gastroenterol 2009; 9: 93
10 Schneider A, Löhr JM, Singer MV. The M-ANNHEIM classification of chronic pancreatitis: introduction of a unifying classification system based on a review of previous classifications of the disease. J Gastroenterol 2007; 42: 101-119
11 Best WR, Becktel JM, Singleton JW. et al. Development of a Crohn’s disease activity index. Gastroenterology 1976; 70: 439-444
12 Child CG, Turcotte JG. Surgery and portal hypertension. In: Child CG. ed. The liver and portal hypertension. Philadelphia: W.B. Saunders & Co; 1964: 50-51
13 Pugh RN, Murray-Lyon IM, Dawson JL. et al. Transection of the esophagus for bleeding esophageal varices. Br J Surg 1973; 60: 646-649
14 Diaconu BL, Ciobanu L, Mocan T. et al. Investigation of the SPINK1 N34S mutation in Romanian patients with alcoholic chronic pancreatitis. A clinical analysis based on the criteria of the M-ANNHEIM classification. J Gastrointestin Liver Dis 2009; 18: 143-150
15 He YX, Xu HW, Sun XT. et al. Endoscopic management of early-stage chronic pancreatitis based on M-ANNHEIM classification system: a prospective study. Pancreas 2014; 43: 829-833
16 Kadiyala V, Lee LS, Banks PA. et al. Cigarette smoking impairs pancreatic duct cell bicarbonate secretion. JOP 2013; 14: 31-38
17 Bouwense SA, Olesen SS, Drewes AM. et al. Is altered central pain processing related to disease stage in chronic pancreatitis patients with pain? An exploratory study. PLoS One 2013; 8: e55460
18 Martinez J, Abad-Gonzalez A, Aparicio JR. et al. The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis). Pancreatology 2013; 13: 8-17
19 Conwell DL, Lee LS, Yadav D. et al. American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: evidence-based report on diagnostic guidelines. Pancreas 2014; 43: 1143-1162
20 Hoffmeister A, Mayerle J, Beglinger C. et al. English language version of the S3-consensus guidelines on chronic pancreatitis: definition, aetiology, diagnostic examinations, medical, endoscopic and surgical management of chronic pancreatitis. Z Gastroenterol 2015; 53: 1447-1195
21 Hartel M, Tempia-Caliera AA, Wente MN. et al. Evidence-based surgery in chronic pancreatitis. Langenbecks Arch Surg 2003; 388: 132-139
22 DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 1988; 44: 837-845
23 von Elm E, Altman DG, Egger M. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 2007; 147: 573-577
24 Frulloni L, Falconi M, Gabbrielli A. et al. Italian consensus guidelines for chronic pancreatitis. Dig Liver Dis 2010; 42 (Suppl. 06) S381-S406
25 Buscher HC, Wilder-Smith OH, van Goor H. Chronic pancreatitis patients show hyperalgesia of central origin: a pilot study. Eur J Pain 2006; 10: 363-370
26 Chauhan S, Forsmark CE. Pain management in chronic pancreatitis: a treatment algorithm. Best Pract Res Clin Gastroenterol 2010; 24: 323-335