Surgical treatment of infected necrosis

Prospective study of 310 patients: can early CT predict the severity of acute pancreatitis?

BACKGROUND

This study was designed to determine the most important early CT parameters predictive of acute pancreatitis severity.

METHODS

Three hundred and seventy-one consecutive patients with acute abdominal pain and hyperamylasemia were enrolled. Three hundred and ten of the 371 patients met our inclusion criteria. Acute pancreatitis severity was evaluated using the 1992 Atlanta criteria. Different CT parameters were reported from the admission abdominal CT by two radiologists blinded from any clinical parameter, but the patients' age and gender. These variables were fitted in a binary logistic regression model.

RESULTS

Acute pancreatitis was mild in 80% cases, severe in 20% cases and lethal in 12.69% cases. The following CT parameters were significantly associated with the severity of acute pancreatitis: the objective size of the pancreas (P = 0.001), the peripancreatic fat abnormalities (P = 0.001) and the extent of necrosis (P = 0.007). Moreover, the age of the patient revealed itself a highly significant (P = 0.001) indicator of disease severity. The association of the four CT criteria eventually showed a sensitivity of 73% and a specificity of 81% to predict acute pancreatitis severity.

CONCLUSION

Although these criteria correlated with disease severity, our study identified that morphological CT criteria cannot be used to triage patients with severe and mild acute pancreatitis.

Infected Pancreatic Necrosis – An Evaluation of the Timing and Technique of Necrosectomy in a Southeast Asian Population

Introduction: Acute pancreatitis appears to be less prevalent in multi-ethnic Southeast Asia, where the aetiology also appears to be influenced by ethnicity. As with acute pancreatitis elsewhere, however, pancreatic necrosis is a cause of significant mortality and the aim of this study was to review our institutional experience with pancreatic necrosectomy. Materials and Methods: The records of all patients who underwent pancreatic necrosectomy from January 2000 to December 2004 were analysed. Indications for surgery were the presence of infected necrosis, unresolving sepsis attributable to ongoing pancreatitis or the presence of gas in the pancreatic bed on imaging. Surgical debridement was achieved by debridement with closure over drains or by debridement with open packing. Results: The cohort comprised 14 of 373 patients admitted for acute pancreatitis (3.8%), with an overall mortality rate of 29%. All patients had infected necrosis with positive bacteriological cultures. Eight patients (57%) underwent debridement with closure over drains and 6 patients (43%) underwent debridement with open packing. All mortalities occurred in patients who underwent open packing, who were also associated with a higher mean Acute Physiology and Chronic Health Evaluation (APACHE) II score. The mortality rate in patients who underwent debridement less than 4 weeks after admission was 33% (2 of 6), compared with 25% (2 of 8) in patients who underwent debridement after 4 weeks. There were no mortalities in patients operated on after 6 weeks. Conclusion: Surgical debridement with closure of drains and a policy of performing delayed necrosectomy are viable in our population. Key words: Necrosectomy, Necrotising pancreatitis, Surgery

Percutaneous drainage of infected pancreatic fluid collections in critically ill patients: correlation with C-reactive protein values

The objective of this study was to assess the efficacy of percutaneous catheter drainage, of early infected pancreatic fluid collections, in critically ill patients with severe acute pancreatitis. The patients in our series had a mean Ranson's score of 5.4. Nineteen (63.3%) of the 30 patients were cured with percutaneous drainage. In this group, the mean C-reactive protein value at the beginning of treatment was 172.8 U/l and 102.5 U/l at the end (P<.001). Cultures yielded multiple organisms in 23 patients (76.7%). The most frequently seen organisms were Escherichia coli, Staphylococcus aureus, and Enterococcus faecium.

Hyperbaric oxygen-induced changes in bacterial translocation and acinar ultrastructure in rat acute necrotizing pancreatitis

BACKGROUND

We aimed to investigate the effects of hyperbaric oxygen therapy on bacterial translocation and acinar cell ultrastructure in a rat model of acute necrotizing pancreatitis.

METHODS

Forty-eight male Sprague-Dawley rats were randomly divided into three groups. Acute pancreatitis was induced in groups II and III. Groups I and II did not receive any treatment, and group III was treated with hyperbaric oxygen. All surviving animals were killed 48 h after the induction of pancreatitis. Bacterial translocation and histological and ultrastructural changes were determined.

RESULTS

The incidence of bacterial translocation in group III was significantly lower in comparison with group II (P<0.001). Histopathological and ultrastructural injury scores were also significantly lower in group III (P<0.001 and P<0.04, respectively).

CONCLUSIONS

Hyperbaric oxygen therapy displayed beneficial effects on pancreatic superinfection and or histopathological and ultrastructural changes in experimental necrotizing pancreatitis.

Clinical laboratory assessment of acute pancreatitis

BACKGROUND

Several biochemical markers in blood and urine have been investigated to establish their clinical application in patients with acute pancreatitis (AP). The relevant studies are reviewed and critically appraised.

METHODS

Medline and the World Wide Web were searched and the relevant literature was classified under the following categories: (1) diagnosis of AP and (2) prediction of: a) disease severity, b) pancreatic necrosis and its secondary infection, c) organ failure and death, and d) disease etiology.

RESULTS AND CONCLUSIONS

Serum lipase is a more reliable diagnostic marker of AP than serum amylase. Urinary strip tests for trypsinogen activation peptide (TAP) and trypsinogen-2 provide a reliable early diagnosis of AP. Useful predictors of severity may include serum procalcitonin and urinary TAP and trypsinogen-2 on admission, serum interleukins-6 and -8 and polymorphonuclear elastase at 24 h, and serum C-reactive protein (CRP) at 48 h. Other markers such as amyloid A and carboxypeptidase B activation peptide (CAPAP) need further investigation. Biochemical prediction of pancreatic necrosis requires 72 h to reach reliability and is impractical. However, the daily monitoring of serum procalcitonin provides a non-invasive detection of infected necrosis; the promising role of phospholipase A(2) in this regard requires further investigation. Early transient hypertransaminasemia reliably predicts biliary etiology, while serum carbohydrate-deficient transferrin and trypsin may predict an alcoholic etiology.

Severe acute pancreatitis: nonsurgical treatment of infected necroses

OBJECTIVES

In acute pancreatitis, infection of necrosis is associated with a substantial mortality of 15% to >50% even if immediate necrosectomy, the recommended standard treatment, is performed, mainly because of the patients' critical systemic and unstable local conditions at the time of manifestation of infection. We investigated whether this dreaded complication can be managed conservatively.

METHODS

We evaluated 88 consecutive patients with severe (APACHE II score, > or =11; Ranson score, > or =4) acute necrotizing pancreatitis who received ICU treatment including early antibiotic prophylaxis. Twenty-eight patients were included who developed infection of necroses, verified by fine needle aspiration, 19 +/- 6 days after admission. No patient received urgent surgery; rather, in all patients, nonsurgical therapy was continued after adapting the antibiotic regimen to bacteriology. In the further course, 12 patients were excluded due to refractory local complications eventually requiring surgical treatment 36 +/- 14 days after diagnosis of infection.

RESULTS

Sixteen patients (APACHE II score: 18.1 [11-33]; Ranson score, 5.9 [4-10]) were managed with medical treatment alone. Six patients recovered without further complications; 10 patients (62%) developed single or multiple organ failure, and 2 died (mortality, 12%).

CONCLUSION

These data suggest that in patients with acute necrotizing pancreatitis and infected necroses, surgery can be avoided without compromising prognosis and outcome.

Antibiotic prophylaxis in severe acute pancreatitis

Severe acute pancreatitis is considered to be a subgroup of acute pancreatitis with the development of local and/or systemic complications. A significant correlation exists between the development of pancreatic necrosis, the frequency of bacterial contamination of necrosis and the evolution of systemic complications. Bacterial infection and the extent of necrosis are determinants for the outcome of severe acute pancreatitis. The late course of necrotizing pancreatitis is determined by bacterial infection of pancreatic and peripancreatic necroses. Mortality increases from 5-25% in patients with sterile necrosis to 15-28% when infection has occurred. The use of prophylactic antibiotics has been recommended in patients with necrotizing pancreatitis. Several controlled clinical trials demonstrated a significant reduction in pancreatic infections or a significant reduction of hospital mortality. However, the results of these clinical trials are controversial and not convincing. Recently, the largest randomized placebo-controlled, double-blind trial has been able to demonstrate that antibiotic prophylaxis with ciprofloxacin and metronidazole has no beneficial effects with regard to the reduction of pancreatic infection and the decrease of hospital mortality. The clinical data from this placebo-controlled trial do not support antibiotic prophylaxis in all patients with necrotizing pancreatitis, but in specific subgroups of patients with pancreatic necrosis and a complicated course.

Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis

BACKGROUND & AIMS

Organ failure is the usual cause of death in acute necrotizing pancreatitis. Our objective was to study whether the extent and infection of pancreatic necrosis correlate with organ failure and mortality.

METHODS

All consecutive patients with acute pancreatitis were prospectively studied. They underwent a detailed clinical and investigative evaluation. Pancreatic necrosis, diagnosed on a computed tomography scan, was graded as <30%, 30%-50%, and >50% necrosis and characterized as either sterile or infected. Logistic regression analysis was done to find out the association of the extent and infection of pancreatic necrosis with organ failure and mortality.

RESULTS

Of 276 patients (mean age, 41.25 years; 172 men), 104 had pancreatic necrosis: 30 had <30% necrosis, 37 had 30%-50% necrosis, and 37 had >50% necrosis; 74 had sterile necrosis, and 30 had infected necrosis. Of them, 37 (35%) patients developed organ failure. Two significant factors were associated with the development of organ failure, the extent of necrosis (<30% necrosis vs 30%-50% necrosis: P = .03; odds ratio [OR], 5.82; 95% confidence interval [CI], 1.15-29.45; <30% necrosis vs >50% necrosis: P = .0004; OR, 18.86; 95% CI, 3.75-94.92) and infected pancreatic necrosis (P = .02; OR, 3.29; 95% CI, 1.17-9.24). The overall mortality was 22%. Infected pancreatic necrosis (P = .006; OR, 4.99; 95% CI, 1.56-16.02) and Acute Physiology, Age, and Chronic Healthy Evaluation II score (P = .004; OR, 1.28; 95% CI, 1.08-1.52) were 2 independent predictors of mortality.

CONCLUSIONS

Extent of necrosis and infected pancreatic necrosis were associated with the development of organ failure in patients with acute necrotizing pancreatitis. Infected pancreatic necrosis was the most significant predictor of mortality.

Infectious complications of pancreatitis: diagnosis and management

Infected pancreatic necrosis is the leading cause of death in patients with severe acute pancreatitis. Early prophylactic antibiotic treatment is effective in preventing conversion of sterile necrosis to pancreatic infection, but its effect on mortality remains unproven. Fungal infections may predict a worse outcome, but no evidence supports the use of antifungal prophylaxis. Because infection of pancreatic necrosis by enteric bacteria can develop despite prophylaxis, a high index of suspicion should allow early detection followed by aggressive management.

Procalcitonin: improved biochemical severity stratification and postoperative monitoring in severe abdominal inflammation and sepsis

BACKGROUND

Infections and sepsis are among the most devastating complications in abdominal surgery and significantly contribute to morbidity and mortality. Early and reliable diagnosis of septic complications is notoriously difficult, and the search for novel approaches to overcome this problem is still a compelling issue for clinicians. Among a large array of inflammatory parameters, procalcitonin (PCT), the 116-amino-acid pro-peptide of calcitonin, has gained considerable importance in identifying patients at risk of developing infection and sepsis in clinical practice.

METHODS

Along with the latest insights into pathophysiological aspects of this pro-hormone, the literature as well as our own experience on the usefulness of PCT determinations in patients with severe inflammatory abdominal disorders was reviewed.

RESULTS

Although the term "sepsis" does not embrace the integral properties of PCT, a remarkable number of clinical studies have demonstrated the pivotal role of this parameter in the host response to microbial and fungal infections. In acute pancreatitis PCT allows early severity stratification and closely correlates with the development of subsequent pancreatic infections. In patients with peritonitis PCT reflects overall disease severity and is an early and reliable indicator of overall prognosis. Postoperative monitoring of PCT is a helpful tool to identify patients with evolving or persisting septic complications after elective and emergency abdominal surgery.

CONCLUSIONS

Compared with established biochemical routine variables, PCT significantly contributes to earlier and better stratification of patients at risk of developing septic complications and provides excellent prognostic assessment in severe abdominal inflammation. The currently available test systems render PCT an applicable and readily available parameter under clinical routine and emergency conditions.

Increasing age and APACHE II scores are the main determinants of outcome from pancreatic necrosectomy

BACKGROUND

The aim of this study was to identify factors associated with death after surgery in patients with extensive pancreatic necrosis.

METHODS

Sixty-four patients who underwent pancreatic necrosectomy between 1996 and 2002 were studied.

RESULTS

The median age was 60.5 (95 per cent confidence interval (c.i.) 57 to 64) years and 40 patients (62.5 per cent) were tertiary referrals. The initial median Acute Physiology And Chronic Health Evaluation (APACHE) II score was 9 (95 per cent c.i. 7.9 to 10.1) and there were 21 deaths (32.8 per cent). Twenty-eight patients (43.8 per cent) underwent minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) and the remainder had open pancreatic necrosectomy (OPN); 44 (72.1 per cent) of 61 patients had infected pancreatic necrosis at the time of the first procedure. Seven patients who underwent MIRP died compared with 14 after OPN (P = 0.240). Patients who died were older than those who survived, with higher APACHE II scores at presentation, and before and after surgery (P = 0.001). Survivors had significantly longer times to surgery than those who died (P = 0.038). All 21 patients who died required intensive care compared with 26 of 43 survivors (P < 0.001). Thirty of 36 patients who had the OPN procedure required intensive care compared with only 17 of 28 patients who had MIRP (P = 0.042). Logistic regression analysis showed that only postoperative APACHE II score was an independent predictor of increased mortality (P = 0.031).

CONCLUSION

Advanced age and increasing APACHE II score, and a need for postoperative intensive care, were the most important predictors of outcome after pancreatic necrosectomy.

Early and long-term results of surgery for severe necrotising pancreatitis

BACKGROUND

Necrotising pancreatitis is a challenging problem for the surgeon, as it is associated with considerable morbidity and mortality. The indications, timing of surgical intervention and type of procedure continue to be debated in an effort to improve the outcome of this devastating disease process.

METHODS

A retrospective analysis of early and long-term results in a series of 44 consecutive patients (34 men, 10 women, median age 46.5, range 13-74 years) who underwent necrosectomy for severe necrotising pancreatitis. In 16 patients necrosectomy and primary abdominal closure with drains was performed, 14 patients had planned staged necrosectomy and delayed abdominal closure with drains, and in 14 patients necrosectomy with open laparostomy was undertaken.

RESULTS

There were 8 deaths (18%) and 14 cases (32%) of significant hospital morbidity (fistula 10, pseudocyst 2, renal failure 2). Variables which correlated with mortality were: high APACHE II score, acute renal failure requiring dialysis, and requirement for surgical intervention at an early stage (within the first two weeks). A total of 28 late complications occurred in 21 of the surviving patients (endocrine pancreatic insufficiency 10, exocrine pancreatic insufficiency 2, pseudocyst 2, chronic renal failure 2, incisional hernia 10, recurrent pancreatitis 1, and chronic pain 1).

CONCLUSIONS

Low mortality can be achieved in patients with severe necrotizing pancreatitis with aggressive surgical intervention and careful perioperative management. Long-term morbidity remains high, and emphasises the need for prolonged follow-up.

Outcome of open necrosectomy in acute pancreatitis

Twenty percent of all acute pancreatitis patients present with necrotizing pancreatitis. Infected necrosis is responsible for 80% of deaths in the course of the disease though, thanks to antibiotic prophylaxis, the infection rate is decreasing. When infection occurs, the prognosis is poor, and the need for debridement and drainage of the necrosis is mandatory. The aim of this study was to review the most recent literature in order to present an update of open surgical management of infected necrosis.

Incidence, etiology, and impact of Fever in patients with acute pancreatitis

BACKGROUND/AIM

Fever, as a significant event, has not been studied systematically in patients with acute pancreatitis. We studied prospectively incidence, etiology, and impact of fever on the management and outcome in patients with acute pancreatitis.

METHODS

All consecutive patients with acute pancreatitis were studied for the development of fever, its etiology, and its influence on the management and outcome of acute pancreatitis. Fever was considered to be significant, if the temperature was >38 degrees C and persisted for >2 days.

RESULTS

A total of 75 patients (51 males; mean age 41 years) with acute pancreatitis were included between January 1997 and June 1998. The causes of pancreatitis were gallstones in 48%, alcohol in 28%, and others in 24% of the patients. 20 patients had pancreatic necrosis, and 45 (60%) developed fever during the course of pancreatitis. The etiology of fever was infected pancreatic necrosis in 8 (18%), pancreatitis per se in 10 (22%), cholangitis in 4 (9%), nonpancreatic infections in 17 (38%), and an undetermined one in 6 (13%) patients. Of the 45 patients with fever, 17 had pancreatic necrosis as compared with only 3 of 30 patients who did not develop fever (p < 0.05). Patients with fever had a higher pancreatitis-related mortality than those without fever (p = 0.03).

CONCLUSIONS

60% of the patients with acute pancreatitis developed fever. Infected pancreatic necrosis was the cause of fever in 18% of the patients and not in the majority, i.e., 82% of the patients. The mortality rate was higher in patients who developed fever than in those who did not.

Deferoxamine and meropenem combination therapy in experimental acute pancreatitis

INTRODUCTION

Recent data from the experimental clinical studies suggest that antibiotics having good penetration to pancreas may reduce mortality by preventing pancreatic infection, which is the most important prognostic factor in acute pancreatitis (AP). Deferoxamine is an active free oxygen radical scavenger, which has been shown to have a protective role in development of acute pancreatitis.

AIM

To determine the effects of combination of deferoxamine and meropenem in acute necrotizing pancreatitis.

METHODOLOGY

One hundred male Sprague-Dawley rats were randomly divided into 5 groups. All rats underwent laparotomy with cannulation of biliopancreatic duct. Group 1 received intraductal saline injection. Acute necrotizing pancreatitis was induced in group 2, 3, 4, and 5 by intraductal injection of 3% taurocholate. Group 1 (sham operated) and group 2 were injected with saline of 0.3 mL/kg intraperitoneally (i.p). Group 3 was injected with meropenem 60 mg/kg/d i.p, group 4 with deferoxamine 80 mg/kg/d s.c and group 5 with combination of these 2 agents at the same doses. While meropenem was started 2 hours later, all treatments were started immediately after the induction of pancreatitis. All rats were killed at the 48th hour of the treatment and blood and tissue samples were collected for amylase determinations, pathologic examinations, and culture.

RESULTS

There was no difference in serum amylase levels between AP induced groups (P > 0.05). Pancreatic histology scores were significantly low in rats treated with deferoxamine (group 4), and combination regimen (group 5) (P < 0.001). Meropenem significantly reduced the incidence of pancreatic infection. Although combination of deferoxamine with meropenem showed better effects than meropenem alone in terms of pancreatic infection, the difference did not reach to statistical significance.

CONCLUSIONS

Meropenem treatment reduces secondary pancreatic infections in acute pancreatitis. Treatment with deferoxamine and meropenem combination may be more beneficial than single therapies in reducing the severity of pancreatitis. Further studies investigating the effects of this combination on survival are needed.

Acute pancreatitis: treatment strategies

Acute pancreatitis is an acute painful abdominal disease of sudden onset that ranges from a mild and self-limited illness to a severe and severe life-threatening condition. In spite of decades of intensive research, there are no causal therapeutic options. Treatment relies on supportive treatment principles based on adequate volume replacement to compensate for fluid loss in the intraperitoneal space and analgesics for pain relief. In cases with acute pancreatitis predicted to have a severe course of the disease, antibiotic therapy is recommended to avoid infection of pancreatic necrosis. Despite a substantial set of clinical trials in favor of antibiotic treatment to reduce morbidity, there is no general consensus on the prophylactic antibiotic treatment. Adequate nutritional support is required for patients with severe acute pancreatitis and a protracted course of the disease. Enteral nutrition appears to be superior to enteral nutrition.

[Acute pancreatitis]

While interstitial acute pancreatitis usually takes a benign course, necrotizing acute pancreatitis takes a severe course, mainly because of severe local and systemic complications. After a quick diagnosis it is necessary to rapidly assess a degree of severity of the disease and thus the prognosis. The clinical picture and the result of imaging procedures do not always correspond. The management basically includes to treat pain as well as to administer fluid, electrolyte, protein and calories. In addition, systemic treatment of complications such as shock or respiratory and renal insufficiency--if occurring--is necessary. In case of pancreatic necrosis, prophylactic administration of pancreas-penetrable antibiotics is recommended to avoid infection. In the severely ill with infected pancreatic necrosis, surgery is the treatment of choice. In approximately 10% of all patients with alcohol-induced pancreatitis, there is a gradual transition to chronic pancreatitis.

Management of severe acute pancreatitis

BACKGROUND

Acute pancreatitis is still associated with significant morbidity and mortality. Current management guidelines are sometimes equivocal, particularly in relation to the surgical treatment of severe disease. This review assesses available investigative and treatment strategies to allow the development of a formalized management approach.

METHODS

A literature review of diagnosis, staging and management of acute pancreatitis was performed.

RESULTS AND CONCLUSION

Recent evidence has helped to clarify the roles of computed tomography, endoscopic retrograde cholangiopancreatography, prophylactic antibiotics, enteral feeding and fine-needle aspiration for bacteriology in the management of acute pancreatitis. Despite a relative shortage of prospective randomized trials there has been a significant change in the surgical management of acute pancreatitis over the past 20 years. This change has been away from early aggressive surgical intervention towards more conservative management, except when infected necrosis is confirmed. A formalized approach, with appropriate use of the various non-surgical and surgical options, is feasible in the management of severe acute pancreatitis.

Macrophage migration inhibitory factor is a critical mediator of severe acute pancreatitis

BACKGROUND & AIMS

Macrophage migration inhibitory factor (MIF), originally described as an inhibitor of the random migration of macrophages, has been shown recently to be involved in the pathogenesis of several inflammatory diseases such as sepsis. The aim of this study was to clarify the role of MIF in acute pancreatitis (AP).

METHODS

Hemorrhagic necrotizing pancreatitis and edematous pancreatitis were induced by the injection of taurocholic acid (TCA pancreatitis) and cerulein (cerulein pancreatitis), respectively, on male Wistar rats. MIF levels in ascitic fluids, serum, and the organs were determined. The effects of anti-MIF antibody were examined on the prognosis of rats with TCA pancreatitis and of female CD-1 mice with choline-deficient, ethionine-supplemented, diet-induced model of severe AP. In addition, serum MIF levels in AP patients and in healthy controls were measured.

RESULTS

Serum and ascitic MIF levels in TCA pancreatitis were increased rapidly and decreased gradually thereafter. Ascitic MIF levels were also increased in cerulein pancreatitis, but to a lesser degree. MIF level was increased in the lung in TCA pancreatitis, but not in the pancreas and the liver. Prophylactic (1 hour before and immediately after induction) administration of anti-MIF antibody significantly improved the survival rate of rats with TCA pancreatitis. The survival rate of mice with severe AP was also improved significantly by the antibody treatment. Serum MIF levels were higher in severe AP patients than mild AP patients and healthy controls.

CONCLUSIONS

These results suggest a role of MIF in the pathogenesis of severe AP.

Role of the gut in the course of severe acute pancreatitis

INTRODUCTION

The pathogenesis of acute pancreatitis remains elusive. Sepsis and multiple organ failure continue to cause death (overall mortality rate, approximately 10%) despite immense improvements in supportive, radiologic, and surgical therapy. The gut appears to play a key role in the development of these complications.

AIM

To critically review the evidence implicating the gut in the pathogenesis of acute pancreatitis.

METHODS

Relevant English-language literature or abstracts cited in the MEDLINE database were reviewed.

RESULTS AND CONCLUSION

Gram-negative enteric organisms account for most infections of pancreatic necrosis and subsequent sepsis, which suggests the gut as a source. Intestinal permeability is increased early in patients with severe acute pancreatitis and correlates with endotoxemia, which suggests translocation as a possible mechanism. The pathogenesis of the deranged function of the gut mucosal barrier and the possible sites of increase in intestinal permeability are discussed. The gut also plays a role in priming neutrophils and the release of inflammatory cytokines, which initiate and propagate nearly all the detrimental consequences of severe inflammation and sepsis. Future research avenues and potential therapeutic measures that may restore and preserve gut barrier function are explored.

Inflammatory cytokines, C reactive protein, and procalcitonin as early predictors of necrosis infection in acute necrotizing pancreatitis

BACKGROUND

Infection of necrosis is a major risk factor in patients with acute pancreatitis. Systematic use of broad spectrum antibiotics has been recommended in these patients but may induce serious side effects. To better target patients in whom antibiotic prophylaxis could be beneficial, we evaluated whether early serum profiles of interleukin 6 (IL-6), tumor necrosis factor (TNF-alpha, C reactive protein (CRP) and procalcitonin (PCT) help to discriminate between patients who eventually develop infection of necrosis and those who do not.

METHODS

Forty-eight patients with acute pancreatitis and a computed tomography (CT) severity index score of more than 3 were prospectively screened. They were then separated into infected and non-infected groups according to the occurrence of infected pancreatic necrosis. The severity of illness was assessed with Ranson's classification and Simplified Acute Physiologic Score II. Serum levels of IL-6, TNF-alpha, CRP, and PCT were measured during the first 3 days after admission. CT-guided fine needle aspiration of pancreatic necrosis was performed to prove infection when sepsis of abdominal origin was suspected. Using the methodology of receiver operating curves, we determined the presence of a threshold for markers that would be predictive of the development of infected necrosis.

RESULTS

PCT and IL-6 were higher in the serum of patients who eventually developed infection of necrosis (P < 0.003 and < 0.04, respectively). No difference was noted between the 2 groups for TNF- alpha and CRP. The combination of IL-6 < 400 pg/l and PCT < 2 ng/L best identified patients who were not at risk for necrosis infection. The negative predictive value for these thresholds was 91%, whereas sensitivity and specificity were 75% and 84%.

CONCLUSIONS

PCT and IL-6 serum levels were elevated very early in patients who eventually developed necrosis infection. A combination of PCT and IL-6 thresholds could be helpful in identifying a subgroup of patients in whom antibiotic prophylaxis is likely to be ineffective.

[Surgical treatment of acute pancreatitic with infected necrosis by necrosectomy-pancreatostomy]

Technical modalities of surgical treatment of infected pancreatic necrosis remains controversial. The aim of this retrospective study was to assess the results of necrosectomy associated by pancreatostomy using active drainage according Mikulicz, which is currently an unusual technique.

PATIENTS AND METHODS

From 1985 to 1997, 18 consecutive patients (median age = 63; range = 35-88 years) were operated on through laparotomy for infected necrosis and treated by necrosectomy combined with Mikulicz drainage. Fourteen patients were referred from another center, including 9 who had previous surgery. Necrosectomy was performed after a median delay of 22 days (1-45) after onset of pancreatitis, in all patients because of severe sepsis (including 12 patients with persisting shock) and presence at CT scan of necrotic collections containing gas bubbles (n = 15) and/or infection proven by percutaneous aspiration (n = 3).

RESULTS

After the first procedure, patients underwent between 2 and 25 (median: 5) additional necrosectomies through the pancreatostomy tract. Thirteen surgical complications were observed in 8 patients: digestive fistula (n = 7), intraabdominal bleeding (n = 3), gastrointestinal haemorrhage (n = 1), colic stenosis with colectasy (n = 1). Five patients, all referred from another center, died (28%) between the 47th and the 140th day from multiorgan failure (n = 4) or gastrointestinal haemorrhage (n = 1). The median hospital stay was 109 days (26-265) including 51 in intensive care unit (1-134). The 13 surviving patients were followed during an average of 2 years (4 months-7 years). All developed an incisional hernia of the pancreatostomy tract, which was surgically treated in 6 cases.

CONCLUSIONS

Necrosectomy-pancreatostomy is an appropriate treatment of acute pancreatitis with infected necrosis, despite the usual need of additional but easy necrosectomies, and the frequent occurrence of incisional hernia. Results observed in patients referred to our center suggest that earlier diagnosis of necrosis infection using percutaneous aspiration could improve the prognosis.

Streptococcus pneumoniae as an etiologic agent in infectious complications of pancreatic disease

Systematic culturing of perioperative intra-abdominal samples allowed us to recognize the presence of Streptococcus pneumoniae in infectious complications of chronic pancreatitis in 9 male patients. In 8 of 10 of the intra- or peripancreatic samples, S. pneumoniae was the single isolate identified. All but one of the S. pneumoniae isolates were sensitive to penicillin. The patients had predisposing underlying conditions such as alcoholism and diabetes mellitus. All patients were cured due to adequate surgery and antibiotic treatment. Analysis of the case histories suggests that S. pneumoniae may have been a relevant organism causing the infectious complications of pancreatitis in these patients.

Incidence, spectrum and antibiotic sensitivity pattern of bacterial infections among patients with acute pancreatitis

BACKGROUND AND AIM

Secondary infection of pancreatic necrotic tissue and peripancreatic fluid is a serious complication of acute pancreatitis resulting in significant morbidity and mortality. The aim of this study was to find out the spectrum of bacterial infections, and their antibiotic sensitivity pattern in patients with acute pancreatitis.

METHODS

All consecutive patients with acute pancreatitis were studied prospectively. Detailed investigations were carried out to identify bacterial infections and their antibiotic sensitivities in patients with suspected infection. These investigations included cultures of various body fluids, throat swabs, indwelling cannula and catheter tips. Pancreatic tissue was obtained by using needle aspiration or at surgery for Gram's stain, culture and sensitivity. All cultures were repeated until the presence of infection was confirmed or excluded.

RESULTS

A total of 169 patients with acute pancreatitis were studied during the period between January 1997 and June 2000 (mean age 41.3 years; 116 males and 53 females). Of the 169 patients, 63 had infections at various sites. A total of 80 cultures were positive, and 12 different bacterial isolates were cultured from samples taken from these 63 patients. Polymicrobial infection was seen in 32% of patients. Twenty-four patients had a confirmed pancreatic infection. Blood cultures had a growth of organisms in 19 patients, with evidence of ongoing or worsening pancreatitis, thus raising a strong suspicion of infected necrosis in them. The commonest organisms were Escherichia coli from 20 cultures and Pseudomonas aeruginosa from 18 cultures. The antibiotic sensitivity pattern showed that most bacteria were sensitive to third generation cephalosporins and quinolones; notably among them were cefotaxime, ceftazidime, and ciprofloxacin.

CONCLUSION

Bacterial infections were seen in 37% of patients with acute pancreatitis. The commonest organisms were Pseudomonas aeruginosa and Escherichia coli. Most bacterial isolates were sensitive to third generation cephalosporins and quinolones.

A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis

BACKGROUND

The end result of leakage of pancreatic juice into the peripancreatic space can be sterile necrosis, infected necrosis, or rupture into an adjacent hollow viscus or blood vessel (eg, colon, small bowel, or pseudoaneurysm). If a pancreatic duct (PD) leak is present, should treatment be aimed at minimizing the sequela of the leakage of pancreatic juice and not just supportive observation until a necrosectomy is required?

METHODS

In 144 patients with severe pancreatitis we investigated whether the presence of a PD leak was associated with necrosis and also asked if PD leak might predict other outcomes such as a length of stay (LOS), mortality, and need for surgery. Furthermore, we questioned whether the use of endoscopic retrograde cholangiopancreatography (ERCP) to search for a PD leak might worsen the clinical outcome because of the potential for introducing microorganisms into an undrained space or exacerbating pancreatitis.

RESULTS

The presence of a demonstrable pancreatic duct leak was observed in 37% of patients and was significantly associated with both a higher incidence of necrosis and prolonged LOS (> or = 20 days). These patients were 3.4 times more likely to have necrosis and 2.6 times more likely to have a prolonged LOS. When treated with a combination of percutaneous drains, pancreatic duct stents, and surgery as necessary, a PD leak (even with its higher necrosis rate) was not significantly correlated with either mortality or the need for necrosectomy. The use of ERCP was not associated with LOS, mortality, or the need for necrosectomy, provided discovered PD leaks were immediately drained.

CONCLUSIONS

A PD leak is common in patients with pancreatic necrosis but it is also important to locate and decompress in order to impede progression of the disease and keep mortality low.

Diagnostic relevance of procalcitonin, IL-6, and sICAM-1 in the prediction of infected necrosis in acute pancreatitis

BACKGROUND

Infected pancreatic necrosis (IPN) is an absolute indication for surgical intervention, therefore an early and accurate laboratory diagnosis is necessary to confirm the infection. The aim of the study was to analyze the clinical value of procalcitonin (PCT) for the prediction of infected necrosis, in comparison with interleukin-6 (IL-6) and sICAM 1.

PATIENTS AND METHODS

A total of 30 patients were investigated; 10 patients with sterile pancreatic necrosis (SPN), 10 with IPN, and 10 with sepsis of different origin. The concentrations of PCT in the patients' sera were measured by immunoluminometric assay (BRAHMS Diagnostica, Berlin, Germany, PCT Lumitest), the IL-6 concentrations by bioassay, applying the B-9 cell line, and the sICAM-1 levels by enzyme-linked immunosorbent assay (ELISA) (R&D). PCT was determined in cell lysates by ECL Western blot.

RESULTS

PCT was found in relatively high concentrations (8.5 +/- 4.8 ng/mL) only in patients with infected pancreatic necrosis, and in patients with sepsis of different origin ( 15 +/- 5.4 ng/mL). Positive values (> 1 ng/mL) preceded positive bacterial results from either blood or surgical samples. None of the serum samples of patients with SPN exhibited PCT concentrations higher than 1.2 ng/mL. In contrast, IL-6 and sICAM-1 were overproduced in both types (infected and sterile) of pancreatic necrosis, and their levels remained elevated for several days even after surgical elimination of the infected focus (widespread necrosectomy and continuous lavage). Sensitivity, specificity, and positive predictive values for discriminating IPN from SPN was 90, 100, and 100% for PCT (p < 0.0001); 100, 20, and 55% for IL-6 (p 0.474 n.s.) and 90, 10, and 50% for sICAM-1 (p 1.000 n.s.). Immunoblotting revealed no PCT in patients' leukocytes, or in human endothelial cell lines.

CONCLUSION

Elevated serum IL-6 and sICAM-1 levels are characteristic in systemic inflammatory response syndrome (SIRS) of either infectious or noninfectious origin. In contrast, the PCT level is an accurate, readily available parameter that allows the discrimination of IPN, and is a helpful marker facilitating a decision concerning surgical intervention.

Kupffer cell blockade reduces hepatic and systemic cytokine levels and lung injury in hemorrhagic pancreatitis in rats

Severe acute pancreatitis (AP) is associated with both the local (pancreatic) release of cytokines and an elevation in their systemic plasma concentrations. This may lead to organ dysfunction and death of the patient. The aims of this study were to investigate the source(s) of systemic cytokine production during experimental AP. Forty-two rats were allocated to five groups (control, sham operation and saline injection, sham operation and gadolinium chloride injection, intraductal sodium-taurocholate infusion and saline injection, or intraductal sodium-taurocholate infusion and gadolinium chloride injection). Blood from the iliac artery, portal vein, and hepatic vein, along with tissue from the pancreas, liver, and lung, were collected. Serum levels of TNFalpha, IL-1beta, IL-6, and IL-10 were determined by enzyme-linked immunosorbent assay. Tissue mRNA for IL-1beta and IL-10 was assessed by reverse-transcription polymerase chain reaction. In untreated animals with AP, the lowest serum cytokine levels were found in the portal vein. In the hepatic vein, the levels of TNFalpha, IL-1beta, and IL-6 were higher. The highest serum levels were detected in the systemic circulation. In the gadolinium chloride-treated group, there was no increase in hepatic or systemic cytokine levels and less lung injury was observed. Extrapancreatic cytokine production from both the liver and the lung contributed significantly to systemic levels of TNFalpha, IL-1beta, IL-6, and IL-10 in this experimental model of AP.

Does mortality occur early or late in acute pancreatitis?

Several prior studies have suggested that 80% of deaths in acute pancreatitis occur late as a result of pan-creatic infection. Others have suggested that approx half of deaths occur early as a result of multisystem organ failure. The aim of the present study was to determine the timing of mortality of acute pancreatitis at a large tertiary-care hospital in the United States.

METHODS

Patients with a diagnosis of acute pancreatitis (ICD-9 code 577.0) admitted to Brigham and Women's Hospital from October 1, 1982 to June 30, 1995 were retrospectively studied to determine total mortality, frequency of early vs late deaths, and clinical features of patients with early (< or = 14 d after admission) or late deaths (> 14 d after admission).

RESULTS

The overall mortality of acute pancreatitis was 2.1% (17 deaths among 805 patients). Eight deaths (47%) occurred within the first 14 d of hospitalization (median d 8, range 1-11 d), whereas 9 occurred after 14 d (median d 56, range 19-81). Early deaths resulted primarily from organ failure. Late deaths occurred postoperatively in 8 patients with infected or sterile necrosis and 1 patient with infected necrosis treated medically.

CONCLUSION

Approximately half of deaths in acute pancreatitis occur within the first 14 d owing to organ failure and the remainder of deaths occur later because of complications associated with necrotizing pancreatitis. Improvement in mortality in the future will require innovative approaches to counteract early organ failure and late complications of necrotizing pancreatitis.

Diagnostic relevance of procalcitonin, IL-6, and sICAM-1 in the prediction of infected necrosis in acute pancreatitis

BACKGROUND

Infected pancreatic necrosis (IPN) is an absolute indication for surgical intervention, therefore an early and accurate laboratory diagnosis is necessary to confirm the infection. The aim of the study was to analyze the clinical value of procalcitonin (PCT) for the prediction of infected necrosis, in comparison with interleukin-6 (IL-6) and sICAM 1.

PATIENTS AND METHODS

A total of 30 patients were investigated; 10 patients with sterile pancreatic necrosis (SPN), 10 with IPN, and 10 with sepsis of different origin. The concentrations of PCT in the patients' sera were measured by immunoluminometric assay (BRAHMS Diagnostica, Berlin, Germany, PCT Lumitest), the IL-6 concentrations by bioassay, applying the B-9 cell line, and the sICAM-1 levels by enzyme-linked immunosorbent assay (ELISA) (R&D). PCT was determined in cell lysates by ECL Western blot.

RESULTS

PCT was found in relatively high concentrations (8.5 +/- 4.8 ng/mL) only in patients with infected pancreatic necrosis, and in patients with sepsis of different origin ( 15 +/- 5.4 ng/mL). Positive values (> 1 ng/mL) preceded positive bacterial results from either blood or surgical samples. None of the serum samples of patients with SPN exhibited PCT concentrations higher than 1.2 ng/mL. In contrast, IL-6 and sICAM-1 were overproduced in both types (infected and sterile) of pancreatic necrosis, and their levels remained elevated for several days even after surgical elimination of the infected focus (widespread necrosectomy and continuous lavage). Sensitivity, specificity, and positive predictive values for discriminating IPN from SPN was 90, 100, and 100% for PCT (p < 0.0001); 100, 20, and 55% for IL-6 (p 0.474 n.s.) and 90, 10, and 50% for sICAM-1 (p 1.000 n.s.). Immunoblotting revealed no PCT in patients' leukocytes, or in human endothelial cell lines.

CONCLUSION

Elevated serum IL-6 and sICAM-1 levels are characteristic in systemic inflammatory response syndrome (SIRS) of either infectious or noninfectious origin. In contrast, the PCT level is an accurate, readily available parameter that allows the discrimination of IPN, and is a helpful marker facilitating a decision concerning surgical intervention.

Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience

OBJECTIVE

To describe the development of a minimally invasive technique aimed at surgical debridement in addition to simple drainage of the abscess cavity.

SUMMARY BACKGROUND DATA

Surgical intervention for secondary infection of pancreatic necrosis is associated with a death rate of 25% to 40%. Although percutaneous approaches may drain the abscess, they have often failed in the long term as a result of inability to remove the necrotic material adequately.

METHODS

Fourteen consecutive patients with infected necrosis secondary to acute pancreatitis were studied. The initial four patients underwent sinus tract endoscopy along a drainage tract for secondary sepsis after prior open necrosectomy. This technique was then modified to allow primary debridement for proven sepsis to be carried out percutaneously in a further 10 patients. The techniques and initial results are described.

RESULTS

Additional surgery for sepsis was successfully avoided in the initial four patients managed by sinus tract endoscopy, and none died. Of the following 10 patients managed by percutaneous necrosectomy, 2 died. The median inpatient stay was 42 days. There was one conversion for intraoperative bleeding. Eight patients recovered and were discharged from the hospital after a median of three percutaneous explorations. Only 40% of patients required intensive care management after surgery.

CONCLUSIONS

These initial results in an unselected group of patients are encouraging and show that unlike with percutaneous or endoscopic techniques, both resolution of sepsis and adequate necrosectomy can be achieved. The authors' initial impression of a reduction in postoperative organ dysfunction is particularly interesting; however, the technique requires further evaluation in a larger prospective series.

New approaches in surgical management of severe acute pancreatitis

Despite many prospective randomized clinical studies a specific pharmacotherapy for severe acute pancreatitis is not in sight. To date, the only possibility to influence the prognosis of this severe illness is early diagnosis and prevention of intra- and extrapancreatic necrosis and its subsequent infection. In severe necrotizing pancreatitis the incidence of infected necrosis amounts to 40-70% of all patients within 3 weeks. Thereby, the clinical picture often varies to large extent. Ultrasonographically or computer tomography-guided fine-needle aspiration (FNAC) is a fast and reliable technique for diagnosis with an overall sensitivity of 88% and specificity of 90%. This method should however not be applied too early in the course of necrotizing pancreatitis. Since infection of pancreatic necrosis determines significantly the prognosis of disease, various studies have assessed the efficacy of prophylactic antibiotic treatment in patients. Three prospective randomized studies have shown that prophylaxis significantly minimizes septic complications, only in one study, however, the mortality rate could be improved. Although randomized studies are still mandatory to resolve the controversy, it seems justified to recommend prophylaxis with antibiotics which are capable of penetrating the pancreatic tissue and juice. Sterile necrosis should be treated conservatively, with prophylactic antibiotic treatment for as long as possible. Only if patients worsen despite intensive care medicine, surgical debridement should be considered. In contrast, in patients with infected necrosis immediate surgery is in most cases mandatory. Although in one prospective study conservative treatment did not lead to an enhanced mortality rate, possible delay of surgical treatment may endanger the patient. In order to improve the prognosis of the disease, timely and adequate treatment in specialized units provides the best chances for a good prognosis whereby the severely ill patient should not be treated according to a scheme but to his/her individual needs.

Antibiotic selection for patients with septic shock

Early recognition of the sepsis syndrome, prompt administration of broad-spectrum antibiotics, surgical intervention when indicated, and aggressive supportive care in intensive care units remain the therapeutic strategies for patients with sepsis. Antibiotic selection is based on many factors including the most probable source of infection, the most likely pathogens, and knowledge of antibiotic susceptibility patterns for community- and hospital-acquired infections. Unfortunately, with this approach, mortality remains unacceptably high. Adjuvant therapies such as antiendotoxin antibodies, cytokine antagonists, and anti-inflammatory agents aimed at blunting the host immune response to bacterial infection have provided little clinical benefit to date. As our understanding of the pathophysiology of sepsis progresses, perhaps newer modalities will improve clinical outcome. At this time, preventive strategies, including optimal vaccine use, effective infection control practices, judicious use and care of intravascular lines and indwelling urinary catheters, and appropriate use of anti-infective agents to prevent microbial resistance should be used to decrease the incidence of infection and subsequent sepsis.

The application of immobilized polymyxin B fiber in the treatment of septic shock associated with severe acute pancreatitis: report of two cases

The elimination of endotoxin by direct hemoperfusion over immobilized polymyxin B fiber (PMX-F) was carried out in two patients who developed septic shock associated with severe acute pancreatitis. Parameters such as blood pressure, body temperature, and plasma endotoxin level improved after PMX-F treatment, and the infected lesions were successfully and safely removed by surgery. Although an aggressive operative strategy of debridement with ultimate closure over drains is generally associated with low mortality in patients with this devastating disease, we often hesitate to perform this operation due to the poor condition of the patient in the acute period, with multiple organ failure and/or septic shock status, and also because of the difficulty in diagnosing the pancreatic infection. In this situation, endotoxin elimination using PMX-F is a useful tool for treating secondary pancreatic infections to help the patient recover in preparation for surgery, or for treating perioperative endotoxemia.

Pancreatitis complicated by gland necrosis: evolution of findings on contrast-enhanced CT

PURPOSE

The purpose of this work was to investigate the natural history of pancreatic necrosis on contrast-enhanced CT in patients managed nonoperatively.

METHOD

A computer-based radiology information search revealed 32 patients with pancreatic necrosis who had had serial contrast-enhanced CT scans and were managed nonoperatively. There were 23 men and 9 women with a mean age of 51 years. One hundred forty-five contrast-enhanced CT scans were retrospectively reviewed for the location and extent of necrosis. The medical records of all patients were reviewed.

RESULTS

The 32 patients had a mean Ranson clinical grade of 5.8 (range 3-8). Eighteen of these 32 patients were managed nonoperatively, and 14 patients required a necrosectomy after initial nonoperative management. In the 32 patients, the location of necrosis was in the head (3), body (6), tail (2), head/body (2), head/body/tail (9), body/tail (9), and head/tail (1). Extent of necrosis was 0-25% (9), 26-50% (6), 51-75% (6), and 76-100% (11). The extent of necrosis remained stable during follow-up in 22 (69%) patients and increased during follow-up in 10 (31%). Necrosectomy was performed in six (60%) patients in whom there was an increase in necrosis and eight (36%) patients in whom necrosis was stable. No patient had restoration of normal enhancement in an area that was previously necrotic. There were five patients who were managed nonoperatively (mean follow-up 318 days) in whom the necrosis eventually resorbed, forming a focal parenchymal cleft reminiscent of a scar. Five of the 32 patients died.

CONCLUSION

Pancreatic necrosis as demonstrated by CT tends to remain stable in most patients treated nonoperatively. If the extent of necrosis increases, patients are more likely to require a necrosectomy. In some patients managed nonoperatively, the pancreatic necrosis will resorb, resulting in a fat-replaced cleft reminiscent of a scar.

Management of Pancreatitis

Acute pancreatitis can be mild or severe. Identifying causes helps in preventing recurrent episodes, management of complications, treatment of the underlying disorder, and/ or removal of an etiologic agent. Supportive care, pain control, nutrition, and antibiotic use are discussed. Overall, the goal is to prevent and minimize complications and reduce mortality. Chronic pancreatitis is complex, and the etiology of the abdominal pain is multifactorial. The goal is to eliminate causes and treat underlying disorders that may contribute to the inflammatory process. Management of pain, pancreatic insufficiency, and complications is essential. If medical management is not successful, surgical options should be considered.

Surgical approach in patients with acute pancreatitis. Is infected or sterile necrosis an indication--in whom should this be done, when, and why?

The morbidity and mortality rates of severe acute pancreatitis are related to the degree of pancreatic necrosis that accompanies the attack and to the presence of infection. The decision about whether and when to operate on these patients is often difficult, and it requires mature clinical judgment. Proven infection of pancreatic necrosis is an absolute indication for surgical intervention, at which time surgical doffebridement and drainage should be performed. Most patients with sterile necrosis eventually respond to conservative nonsurgical medical management. In patients who remain critically ill for weeks or whose clinical course deteriorates despite maximal intensive care, surgery may be appropriate. Even when these guidelines are followed, the mortality (15% to 40%) and morbidity (approximately 80%) rates remain high.

Nonsurgical management of acute pancreatitis. Use of antibiotics

In severe AP, infected necrosis is the leading cause of death. Prevention of pancreatic infection is the major goal in the treatment of patients with necrotizing pancreatitis. Adequate early antibiotic therapy seems to be promising in these patients. Their role and the optimal timing of the antibiotic therapy (e.g., benefit of prophylactic application) are discussed. Preliminary results of a study in patients with infected pancreatic necrosis and exclusively or primarily conservative treatment also are presented.

[Percutaneous drainage of infected pancreatic necrosis: an alternative to surgery]

AIM OF THE STUDY

To describe a technique of percutaneous CT guided catheter drainage of infected pancreatic necrosis and to report the results of this technique compared with those of the conventional surgical treatment and of other percutaneous drainage series.

PATIENTS AND METHODS

Between 1992 and 1997, the series included 32 patients who had a severe acute necrotizing pancreatitis with a mean Ranson score of 4.6, scored into grade D (n = 10), and grade E (n = 22), according to the Balthazar radiological staging. Modified Van Sonnenberg 24 F double lumen catheters were used for continuous irrigation and aspiration.

RESULTS

Forty-nine drains were inserted for 41 infected necroses and eight abscesses. Among the 32 patients, the proof of infected necrosis was obtained in 26 patients by fine needle aspiration and culture (enterococcus, staphylococcus, pseudomonas). The average delay of catheter insertion was 23 days after onset of pancreatitis; the mean duration of drainage was 43 days, and an average of three catheters per patient was required. Five patients (15%) died, and among the survivors, 16 (59%) presented 21 complications including 14 enterocutaneous or pancreatic fistulas. A subsequent surgical procedure including two necrosectomies was necessary in six patients.

CONCLUSION

This study demonstrates that percutaneous drainage of infected pancreatic necrosis with a 15% mortality and 70% success rate, represents an interesting alternative to conventional surgery.

Progress in the management and treatment of infected pancreatic necrosis

Infected pancreatic necrosis and sepsis are the leading causes of mortality in necrotizing pancreatitis. A review has been undertaken of the results of the past two decades relating to different surgical treatments of infected pancreatic necrosis. During the period 1978-85, the surgical treatment of necrotizing pancreatitis and its complications in our department consisted of the 'conventional' therapy (resection of the involved pancreatic tissue, or necrosectomy and drainage) in 61 patients, with a mortality rate of 36% (22 patients died). Since 1986, we have performed necrosectomy and other surgical interventions combined with continuous widespread lavage in 142 patients with infected pancreatic necrosis. The overall mortality decreased significantly to 6.3% (9 patients died). This result was achieved by means of aggressive surgical treatment, continuous, prolonged washing and suction drainage and supportive therapy, including immunonutrition, modifying the cytokine production and adequate antibiotic and antifungal medication. This surgical strategy provides the possibility for recovery in cases of necrotizing pancreatitis with septic complications.

Pancreatic necrosis: results of necrosectomy, packing, and ultimate closure over drains

OBJECTIVE

The treatment of pancreatic necrosis at a tertiary referral center was reviewed to effect better patient outcome.

SUMMARY BACKGROUND DATA

Pancreatic necrosis is a devastating disease that leads to death in 10% to 50% of cases. Infected necrosis is particularly deadly because 80% of deaths from necrosis are due to infection or its complications. Therapeutic strategies center on aggressive support of organ systems and prevention and treatment of infectious complications.

METHODS

Records of all patients who underwent pancreatic necrosectomy from 1990 to 1996 at Emory University Hospital were reviewed. Patients with infected necrosis were debrided as soon as the diagnosis was made. Reoperation for completion necrosectomy with ultimate closure over lavage catheters was performed as necessary.

RESULTS

Of the 244 patients admitted with acute pancreatitis in the study period, 50 underwent pancreatic debridement. The mean age was 52 years, and 74% of patients were transferred from other institutions. Eighty-four percent of patients had infected necrosis, and all patients underwent sequential debridement with eventual closure over drains. Organ failure occurred in 72% of cases, and the overall mortality rate was 12%. The mean length of stay was 54 days.

CONCLUSIONS

The management of pancreatic necrosis demands the allocation of extensive resources. An aggressive operative strategy of multiple debridements with ultimate closure over drains can lead to a low mortality rate in patients with this complex disease, but the determination of when to explore patients with sterile necrosis remains difficult.