Necrotizing pancreatitis: contemporary analysis of 99 consecutive cases

Acute pancreatitis severity is exacerbated by intestinal ischemia-reperfusion conditioned mesenteric lymph

OBJECTIVE

To determine the effect of intestinal ischemia-reperfusion (IIR) on acute pancreatitis (AP) and the role of mesenteric lymph.

SUMMARY BACKGROUND DATA

Intestinal ischemia is an early feature of AP and is related to the severity of disease. It is not known whether this contributes to the severity of AP or is a consequence.

METHODS

Two experiments are reported here using intravital microscopy and a rodent model of mild acute pancreatitis (intraductal 2.5% sodium taurocholate). In the first, rats had an episode of IIR during AP that was produced by temporary occlusion of the superior mesenteric artery (30 min or 3 x 10 min) followed by 2h reperfusion. In a second study rats with AP had an intravenous infusion of mesenteric lymph collected from donor rats that had been subjected to IIR. In both experiments the pancreatic erythrocyte velocity (EV), functional capillary density (FCD), leukocyte adherence (LA), histology and edema index were measured.

RESULTS

The addition of IIR to AP caused a decline in the pancreatic microcirculation greater than that of AP alone (EV 42% of baseline vs. 73% of baseline AP alone, FCD 43% vs 72%, LA 7 fold increase vs 4 fold increase). This caused an increased severity of AP as evidenced by 1.4-1.8 fold increase of pancreatic edema index and histologic injury respectively. A very similar exacerbation of microvascular failure and increased pancreatitis severity was then demonstrated by the intravenous infusion of IIR conditioned mesenteric lymph from donor animals.

CONCLUSIONS

Unidentified factors released into the mesenteric lymph following IIR injury are capable of exacerbating AP. This highlights an important role for the intestine in the pathophysiology of AP pathogenesis and identifies mesenteric lymph as a potential therapeutic target.

Review article: Translumenal endoscopic debridement of organized pancreatic necrosis--the first step towards natural orifice translumenal endoscopic surgery

BACKGROUND

Over the last decades, gastrointestinal endoscopy has transformed from serving purely diagnostic purposes to therapeutic applications. One recent major progress is taking the endoscope beyond the gastrointestinal lumen into the peritoneal cavity for diagnostic and therapeutic procedures. The first step towards Natural Orifice Translumenal Endoscopic Surgery (NOTES) was translumenal endoscopic debridement of pancreatic necrosis.

AIM

To overview current status of endoscopic debridement of organized pancreatic necrosis. Finally, we take a short look into the potential future of translumenal endoscopic procedures.

METHODS

Medical databases were searched for relevant publications, dealing with endoscopic debridement of pancreatic necrosis and NOTES.

RESULTS

All current published studies concerning endoscopic debridement of organized pancreatic necrosis were retrospectively performed and relatively small (largest n = 25). Success rates varies from 80-93% and complication rates from 7-20%. There was no procedure related mortality reported. Published NOTES experiments showed feasibility of a variety of transgastric, transcolonic and transvaginal procedures in the porcine model.

CONCLUSION

Endoscopic debridement seems to be an effective and relatively safe minimally invasive therapy in patients with symptomatic organized pancreatic necrosis and is the first step towards NOTES. Further comparative studies need to define its definitive role in the management of these patients.

Endoscopic transmural debridement of symptomatic organized pancreatic necrosis (with videos)

BACKGROUND

Surgical management of pancreatic necrosis is associated with significant morbidity and mortality. Several weeks after an episode of a necrotizing pancreatitis, necrosis can become organized. By the time necrosis becomes organized, endoscopic therapy has the potential to offer an alternative treatment to surgery.

OBJECTIVE

To evaluate the safety and efficacy of endoscopic debridement of organized pancreatic necrosis and to identify procedural aspects that may improve outcome.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

PATIENTS

All consecutive patients who underwent this novel endoscopic approach were included.

INTERVENTIONS

Treatment started with a cystoenterostomy or a cystogastrostomy. The next steps consisted of balloon dilation, up to 18 mm; advancement of an endoscope into the retroperitoneal cavity; and endoscopic debridement of the collection under direct endoscopic vision. Debridement was repeated every 2 days until most necrotic material was evacuated. In addition, nasocystic catheter irrigation was performed manually with saline solution 6 to 8 times a day.

MAIN OUTCOME MEASUREMENTS

Clinical success, number of endoscopic procedures, and complications.

RESULTS

Twenty-five patients were identified, who had undergone debridement of 27 collections. In 11, 13, 2, and 1 collections, 1, 2, 3, and 4 endoscopic debridement procedures, respectively, were performed. There was no mortality. Severe complications that required surgery occurred in 2 patients: hemorrhage in 1 case and perforation of cyst wall in the other. During a median follow-up of 16 months (range 3-38 months), the overall clinical success rate with resolution of the collection and related symptoms was 93%.

LIMITATIONS

Retrospective study.

CONCLUSIONS

In this study, we showed that endoscopic debridement is an effective and relatively safe minimally invasive therapy in patients with symptomatic organized pancreatic necrosis. Further comparative studies are warranted to define its definitive role in the management of these patients.

Combined anterior and posterior open treatment in infected pancreatic necrosis

OBJECTIVE

To compare the results of combined anterior and posterior open treatments (lesser sac marsupialization (LSM) + lumbostomy, LSM + L) in patients with infected pancreatic necrosis (IPN) with a previous experience of isolated LSM and with data in literature.

MATERIALS AND METHODS

Thirty-four consecutive patients operated on for IPN from 1981 to 2005 were divided into two groups based on the surgical technique used: single LSM (n = 23; period A, 1981-1998) and combined LSM + L (n = 11; period B, 1999-2005).

RESULTS

The postoperative mortality rate was 38.1 (n = 8) and 9% (n = 1) during period A and B, respectively. The most important cause of death was recurrent or persistent sepsis with multiple organ failure. The overall postoperative surgical morbidity was 57 (n = 13) and 27.2% (n = 3) in the two consecutive groups.

CONCLUSIONS

IPN is a challenging condition associated with high mortality mainly because of a persistence of sepsis despite surgery. A comparative analysis of many proposed operative procedures is difficult because of the heterogeneity in the reported series. Open approaches seem to be more effective in controlling local infection and systemic sepsis. Combining open anterior and posterior approaches is in our experience an appropriate surgical treatment in IPN patients.

Case-matched comparison of the retroperitoneal approach with laparotomy for necrotizing pancreatitis

BACKGROUND

Minimally invasive necrosectomy through a retroperitoneal approach is gaining popularity for the treatment of necrotizing pancreatitis. There is, however, no substantial evidence from comparative studies in favor of this technique over laparotomy. The aim of this case-matched study was to perform the first head-to-head comparison of necrosectomy by the retroperitoneal approach with laparotomy in patients with necrotizing pancreatitis.

METHODS

Between 2001 and 2005, there were 15 of 841 consecutive acute pancreatitis patients who underwent necrosectomy by the retroperitoneal approach using a small flank incision. These patients were matched for the presence of preoperative organ failure, status of infection, timing of surgery, age, and computed tomography severity index score with 15 of 46 patients treated with necrosectomy by laparotomy and continuous postoperative lavage (CPL).

RESULTS

In addition to all matched preoperative characteristics, there were no significant differences in sex, preoperative intensive care unit (ICU) admission, preoperative ICU stay, preoperative APACHE-II scores, and preoperative multiple organ failure (MOF). Postoperative complications requiring reintervention occurred in six patients in each group (p = 1.000). Postoperative new-onset MOF occurred in 10 patients in the laparotomy/CPL group versus 2 patients in the retroperitoneal approach group (p = 0.008). Six patients died in the laparotomy/CPL group versus 1 patient in the retroperitoneal approach group (p = 0.080).

CONCLUSIONS

The less postoperative organ failure and the trend toward lower mortality may point to a benefit of the retroperitoneal approach over laparotomy. A randomized controlled design is, however, still required to answer definitively the question of which operative technique is preferably for patients with (infected) necrotizing pancreatitis.

Evaluation of diagnostic findings and scoring systems in outcome prediction in acute pancreatitis

AIM: To determine factors related to disease severity, mortality and morbidity in acute pancreatitis.

METHODS: One hundred and ninety-nine consecutive patients were admitted with the diagnosis of acute pancreatitis (AP) in a 5-year period (1998-2002). In a prospective design, demographic data, etiology, mean hospital admission time, clinical, radiological, biochemical findings, treatment modalities, mortality and morbidity were recorded. Endocrine insufficiency was investigated with oral glucose tolerance test. The relations between these parameters, scoring systems (Ranson, Imrie and APACHE II) and patients’ outcome were determined by using invariable tests and the receiver operating characteristics curve.

RESULTS: One hundred patients were men and 99 were women; the mean age was 55 years. Biliary pancreatitis was the most common form, followed by idiopathic pancreatitis (53% and 26%, respectively). Sixty-three patients had severe pancreatitis and 136 had mild disease. Respiratory rate > 20/min, pulse rate > 90/min, increased C-reactive protein (CRP), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) levels, organ necrosis > 30% on computed tomography (CT) and leukocytosis were associated with severe disease. The rate of glucose intolerance, morbidity and mortality were 24.1%, 24.8% and 13.6%, respectively. CRP > 142 mg/L, BUN > 22 mg/dL, LDH > 667 U/L, base excess > -5, CT severity index > 3 and APACHE score > 8 were related to morbidity and mortality.

CONCLUSION: APACHE II score, LDH, base excess and CT severity index have prognostic value and CRP is a reliable marker for predicting both mortality and morbidity.

The efficacy of nonsurgical treatment of infected pancreatic necrosis

OBJECTIVES

We conducted this study to evaluate the efficacy of nonsurgical treatment for patients with infected pancreatic necrosis (IPN).

METHODS

Among 224 patients with acute pancreatitis from 2000 to 2004, there were 31 patients diagnosed as having IPN complication. The diagnostic criteria for IPN were either a positive culture or free gas in the pancreas of patients with acute pancreatic necrosis. Nonsurgical management including percutaneous drainage or endoscopic drainage (ED) followed by vigorous irrigation was initially attempted in all patients. Surgery was planned only when there was no clinical improvement after the initial nonsurgical treatment.

RESULTS

Percutaneous drainage or ED was performed in 18 and 5 patients, respectively. Eight patients received antibiotics only. Four patients (12.9%) (3 from percutaneous drainage group and 1 from ED group) required surgery. Sepsis or fistula developed in 32% and 6% of patients, respectively, and was managed successfully. One patient (3.2%) died as a result of rapidly progressing multiorgan failure. The mean duration of hospitalization was 37 days. During the follow-up period, 7 patients were readmitted because of fever; they were managed by reposition of the drainage tube.

CONCLUSIONS

Intensive nonsurgical treatment is very effective and safe and should be considered as an initial treatment modality for patients with IPN.

Prevalence of primary fungal infections in necrotizing pancreatitis

BACKGROUND/AIMS

Prophylactic use of carbapenems (meropenem and imipenem) and other broad-spectrum antibiotics in necrotizing pancreatitis has been suggested as a risk factor for pancreatic fungal infections. The aim of our study was to determine the prevalence of primary fungal infections and the pattern of antibiotic use in necrotizing pancreatitis at our institution.

METHODS

Records on 689 consecutive patients with acute pancreatitis between 2000 and 2004 were reviewed. Necrotizing pancreatitis was identified by contrast-enhanced computed tomography (CT) scan. Data on antibiotic usage were collected and microbiologic data obtained from radiologic, endoscopic, and surgical interventions (pancreatic aspiration, drain placement or debridement) were reviewed for evidence of fungal infection. Pancreatic fungal infections were classified as primary if the positive culture was obtained at the time of initial intervention.

RESULTS

Among 64 patients with necrotizing pancreatitis, there were no cases of primary pancreatic fungal infections and 7 cases (11%) of secondary pancreatic fungal infections. Fifteen patients (23%) developed pancreatic bacterial infections. Among 62 patients with necrotizing pancreatitis in whom antibiotic exposure was known, 45% received carbapenems for a median duration of only 6 days, and 84% received non-carbapenem antibiotics for a median duration of 14 days.

CONCLUSION

Limited use and short duration of carbapenem therapy may be factors contributing to the absence of primary fungal infections in our study.

Outcome after pancreatic necrosectomy: trends over 12 years at an Indian centre

BACKGROUND

Pancreatic necrosectomy for necrotizing pancreatitis is a formidable operation. There are limited data from the Indian subcontinent regarding outcome and recent trends in management.

METHODS

Patients undergoing pancreatic necrosectomy over a 12-year period were identified from a prospective database. Data regarding the hospital course, complications and outcome were extracted by case file review. Descriptive statistics were used to present the data. An attempt was made to identify trends in management and outcome over the study period.

RESULTS

One hundred and eighteen patients underwent necrosectomy. The median age was 39.5 years (interquartile range, 32-46). Median Acute Physiology And Chronic Health Evaluation II score at admission was 8 (interquartile range, 6-10). Thirty-nine patients (33%) had organ failure at admission. Patients underwent surgery a median of 23 days (interquartile range, 14-34) after onset of illness. There was high incidence of loco-regional complications (68/118, 58%) and organ failure (88/118, 75%) in the postoperative period. The mortality rate was 38%. There was an increase in the median onset to surgery interval (17 vs 25.5 days; P = 0.001), increased use of percutaneous interventions (20 vs 36%; P = 0.05) and decreased mortality (47 vs 29%; P = 0.052) in the later half of the study period.

CONCLUSION

Pancreatic necrosectomy continues to be associated with significant morbidity and mortality in India. A trend towards increased use of percutaneous interventions and delayed surgery is evident.

Declining morbidity and mortality rates in the surgical management of pancreatic necrosis

Surgical management of patients with pancreatic necrosis (PN) has evolved over the last two decades to include prophylactic antibiotics, initial medical management, and delayed surgical intervention. The purpose of this study is to identify changes in morbidity and mortality rates as our methods of surgical management have evolved. One hundred two consecutive patients (59 males and 43 females, mean age 53 +/- 16 years) with PN managed surgically were classified as group I (1993-2001), after the routine use of prophylactic antibiotics (N = 55), and group II (2002-2005), after the use of International Association of Pancreatology (IAP) guidelines for intervention (N = 47). Age, sex, etiology of pancreatitis, percent of necrosis, infected necrosis, and acute physiology and chronic health evaluation II scores were similar between groups. Despite a significant worsening of Balthazar computed tomography scoring in group II patients (p < 0.0001), operative morbidity (49 [89%] vs 34 [72%], p = 0.03), mortality (10 [18%] vs 2 [4%], p = 0.03), and hospital length of stay (38 +/- 33 days vs 26 +/- 23 days, p = 0.04) were significantly less in group II patients. Current methods of surgical management utilizing IAP guidelines have resulted in a decreased operative morbidity, mortality, and hospital length of stay in patients with PN.

Endoscopic retrograde cholangiopancreatography-induced severe acute pancreatitis

BACKGROUND/AIMS

There is scant information in the literature about the outcomes of endoscopic retrograde cholangiopancreatography (ERCP)-induced severe acute pancreatitis (ESAP). Compared to other causes, higher morbidity and mortality have been reported in ERCP-induced acute pancreatitis. We undertook this study to determine the differences between ESAP and SAP due to other causes (OSAP).

METHODS

We retrospectively identified all cases of SAP admitted to our institution during the years 1992-2001. We reviewed the medical records of all SAP patients to obtain information on demographics, interventions, local and systemic complications and outcomes.

RESULTS

We identified 207 patients with SAP, of whom 16 (7.7%) had ESAP and 191 OSAP. There was no difference between ESAP and OSAP with regard to demographics, clinical interventions, local and systemic complications and outcomes. Both groups had a similar mortality (25 vs. 18%).

CONCLUSION

ESAP has a similar morbidity and mortality compared to OSAP.

Contemporary management of infected necrosis complicating severe acute pancreatitis

Pancreatic necrosis complicating severe acute pancreatitis is a challenging scenario in contemporary critical care practice; it requires multidisciplinary care in a setting where there is a relatively limited evidence base to support decision making. This commentary provides a concise overview of current management of patients with infected necrosis, focusing on detection, the role of pharmacologic intervention, and the timing and nature of surgical interventions. Fine-needle aspiration of necrosis remains the mainstay for establishment of infection. Pharmacological intervention includes antibiotic therapy as an adjunct to surgical debridement/drainage and, more recently, drotrecogin alfa. Specific concerns remain regarding the suitability of drotrecogin alfa in this setting. Early surgical intervention is unhelpful; surgery is indicated when there is strong evidence for infection of necrotic tissue, with the current trend being toward 'less drastic' surgical interventions.

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

No debridement is necessary for symptomatic or infected acute necrotizing pancreatitis: delayed, mini-retroperitoneal drainage for acute necrotizing pancreatitis without debridement and irrigation

We sought to determine if necrosectomy can be omitted for complicated acute necrotizing pancreatitis (ANP). Since 1996, we prospectively performed retroperitoneal drainage by introducing a sump drain to the pancreatic head area via a small left flank incision without debridement and irrigation on 19 consecutive complicated ANP patients. We purposely delayed surgery until liquefaction of retroperitoneal tissue reached the left flank. Our patients had a mean Ranson's and APACHE II score of 5.9 (range, 4-8) and 20.1(range, 4-45), respectively. Sixteen available CT showed retroperitoneal liquefaction after 21.3 days (range, 14-26). Operations were delayed for 4.7 weeks (range, 1.3-9.0). No patient succumbed during this period. The indications were infected necrosis in 16 and severe abdominal pain/food intolerance in 3 patients. Average skin incision was 4.0 cm (range, 3-9). Fungi or bacteria were cultured in 15 patients (80.0%). The recovery courses were surprisingly uneventful. Oral intake began within 2.4 days (range, 1-5) and mean hospital stay (16 survivals) was 23.2 days (range, 4-120) after operation. Drains were completely removed 120.6 days (range, 60-250) later from these outpatients. One gastric perforation and one minor duodenal leak were the only procedure-related complications (10.5%). Three patients died (15.8%), although one had a healed ANP. In conclusion, this delay-until-liquefaction strategy without necrosectomy is an easy and effective treatment method.

Questions about the use of antibiotics in acute pancreatitis

BACKGROUND AND OBJECTIVE

The use of antibiotics in acute pancreatitis despite recent clinical trials remains controversial. The aim of this study is to review the latest clinical trials and guidelines about antibiotics in acute pancreatitis and determine its proper use.

METHODS

Through a Medline search, we selected and analyzed pertinent randomized clinical trials and guidelines that evaluated the use of antibiotics in acute pancreatitis. We answered the most frequent questions about this topic.

RESULTS AND CONCLUSION

Based on these clinical trials and guidelines, we conclude that the best treatment currently is the use of antibiotics in patients with severe acute pancreatitis with more than 30% of pancreatic necrosis. The best option for the treatment is Imipenem 3 x 500 mg/day i.v. for 14 days. Alternatively, Ciprofloxacin 2 x 400 mg/day i.v. associated with Metronidazole 3 x 500 mg for 14 days can also be considered as an option.

The management of suspected pancreatic sepsis

The management of infected pancreatic necrosis is centered on image-guided fine needle aspiration followed by antibiotic therapy that is based on microbiologic culture results. The authors favor targeted antibiotic therapy rather than routine prophylactic antibiotic coverage. Prompt surgical debridement is recommended for patients who have infected necrosis who are suitable operative candidates. Newer surgical, percutaneous, and endoscopic techniques, as well as prolonged antibiotic therapy without intervention, are being evaluated as alternatives to operative debridement. Well-designed prospective trials will help to determine optimal treatment for patients who have infected pancreatic necrosis.

Surgical intervention in patients with necrotizing pancreatitis

BACKGROUND

This study evaluated the various surgical strategies for treatment of (suspected) infected necrotizing pancreatitis (INP) and patient referrals for this condition in the Netherlands.

METHODS

This retrospective study included all 106 consecutive patients who had surgical treatment for INP in the period 2000-2003 in one of eight Dutch university medical centres including three teaching hospitals. Surgical approaches included an open abdomen strategy, laparotomy with continuous postoperative lavage, minimally invasive procedures or laparotomy with primary abdominal closure. The National Hospital Registration System was searched to identify patients with acute pancreatitis who were admitted to the 90 Dutch hospitals that did not participate in the present study.

RESULTS

The overall mortality rate was 34.0 per cent, 70 per cent (16 of 23) for the open abdomen strategy, 25 per cent (13 of 53) for continuous peritoneal lavage, 11 per cent (two of 18) for minimally invasive procedures and 42 per cent (five of 12) for primary abdominal closure (P < 0.001). During the study interval, 44 (12.2 per cent) of 362 patients with acute pancreatitis who were likely to require surgical intervention had been referred to university medical centres.

CONCLUSION

Laparotomy with continuous postoperative lavage is the surgical strategy most often used in the Netherlands. The results of the open abdomen strategy are poor whereas a minimally invasive approach seems promising.

ESPEN Guidelines on Enteral Nutrition: Pancreas

The two major forms of inflammatory pancreatic diseases, acute and chronic pancreatitis, require different approaches in nutritional management, which are presented in the present guideline. This clinical practice guideline gives evidence-based recommendations for the use of ONS and TF in these patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. In mild acute pancreatitis enteral nutrition (EN) has no positive impact on the course of disease and is only recommended in patients who cannot consume normal food after 5-7 days. In severe necrotising pancreatitis EN is indicated and should be supplemented by parenteral nutrition if needed. In the majority of patients continuous TF with peptide-based formulae is possible. The jejunal route is recommended if gastric feeding is not tolerated. In chronic pancreatitis more than 80% of patients can be treated adequately with normal food supplemented by pancreatic enzymes. 10-15% of all patients require nutritional supplements, and in approximately 5% tube feeding is indicated.

JPN Guidelines for the management of acute pancreatitis: surgical management

Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2-3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.

Endoscopic sphincterotomy permits interval laparoscopic cholecystectomy in patients with moderately severe gallstone pancreatitis

Patients with moderately severe gallstone pancreatitis with substantial pancreatic and peripancreatic inflammation, but without organ failure, frequently have an open cholecystectomy to prevent recurrent pancreatitis. In these patients, prophylactic endoscopic retrograde cholangiography (ERC) with endoscopic sphincterotomy (ES) may prevent recurrent pancreatitis, permit laparoscopic cholecystectomy, and decrease risks. The medical records of all patients with pancreatitis undergoing cholecystectomy from 1999-2004 at the University of North Carolina Memorial Hospital were reviewed. Data regarding demographics, clinical course, etiology of pancreatitis, operative and endoscopic interventions, and outcome were extracted. Moderately severe gallstone-induced pancreatitis was defined as pancreatitis without organ failure but with extensive local inflammation. Thirty patients with moderately severe gallstone pancreatitis underwent ERC and ES and were discharged before cholecystectomy. Mean interval between ES and cholecystectomy was 102 +/- 17 days. Cholecystectomy was performed laparoscopically in 27 (90%) patients, open in three (10%) patients, and converted to open in two (7%) patients, with a morbidity rate of 7% (two patients). No patient required drainage of a pseudocyst or developed recurrent pancreatitis. Interval complications resulted in hospital readmission in seven (23%) patients. In conclusion, recurrent biliary pancreatitis in patients with moderately severe gallstone pancreatitis is nil after ERC and ES. Hospital discharge of these patients permits interval laparoscopic cholecystectomy, but close follow-up is necessary in these potentially ill patients.

Case-control comparison of laparoscopic versus open distal pancreatectomy

Laparoscopic distal pancreatectomy is becoming an increasingly used modality in the surgical treatment of pancreatic disease. The assumption is that this will lead to shorter hospitalization and faster recovery. However, actual comparative data between open and laparoscopic distal pancreatectomy is lacking. The purpose of this study is to compare these surgical procedures. All patients who underwent either laparoscopic or open distal pancreatectomy/splenectomy were reviewed. Fifteen patients underwent laparoscopic resection, whereas 41 underwent an open resection. The 15 laparoscopic patients were matched to 15 open patients for age, gender, and pancreatic pathology. Data gathered included length of stay, pancreatic leak, postoperative complications, and return to normal activity. Of the 15 laparoscopic patients, three were converted to open operations. Laparoscopic patients had a median length of stay of 5 days (range, 3-9) compared with 8 days (range, 6-23) for the open patients (P = 0.02). The pancreatic leak rate was 13% in each group. Overall postoperative complication rate was 20% in the laparoscopic group compared with 27% in the open group. Laparoscopic patients reported a return to normal activity in 3 weeks (range, 2-7) compared with 6 weeks (range, 4-10) for open patients (P = 0.03). Laparoscopic distal pancreatectomy/splenectomy does lead to shorter hospital stay and faster return to normal activity. Pancreatic leak rate and overall complication rate appear similar.

Nutrition in pancreatic diseases

The pancreas plays a major role in nutrient digestion. Therefore, in both acute and chronic pancreatitis, exocrine and endocrine pancreatic insufficiency can develop, impairing digestive and absorptive processes. These changes can lead to malnutrition over time. In parallel to these changes, decreased caloric intake and increased metabolic activity are often present. Nutritional deficiencies negatively affect outcome if they are not treated. Nutritional assessment and the clinical severity of the disease are important for planning any nutritional intervention. In severe acute pancreatitis, enteral nutrition with a naso-jejunal feeding tube and a low molecular diet displays clear advantages compared to parenteral nutrition. Infectious complications, length of hospital stay and the need for surgery are reduced. Furthermore, enteral nutrition is less costly than parenteral nutrition. Parenteral nutrition is reserved for patients who do not tolerate enteral nutrition. Abstinence from alcohol, dietary modifications and pancreatic enzyme supplementation is sufficient in over 80% of patients with chronic pancreatitis. In addition, oral supplements are helpful. Enteral nutrition can be necessary if weight loss continues. Parenteral nutrition is very seldom used in patients with chronic pancreatitis.

Surgery in the treatment of acute pancreatitis--minimal access pancreatic necrosectomy

Between 5% and 10% of patients with acute pancreatitis will develop infected pancreatic necrosis. Traditional open surgery for this condition carries a mortality rate of up to 50%, and therefore a number of less invasive techniques have been developed, including radiological drainage and a minimal access retroperitoneal approach. No randomised controlled trials have been published which compare these techniques. Indications for minimal access surgery are the same as for open surgery, i.e. infected pancreatic necrosis or failure to improve with extensive sterile necrosis. Access is obtained to the pancreatic necrosis via the left loin and necrosectomy performed using an operating nephroscope, and this often requires several procedures to remove all necrotic tissue. The cavity is continuously irrigated on the ward in between procedures. The results of this approach are encouraging, with less systemic upset to the patient, a lower incidence of post-operative organ failure when compared with open surgery, and a reduced requirement for ITU support. There is also a trend towards a lower mortality rate, although this does not reach statistical significance on the data published so far. Current evidence suggests that a minimal access approach to pancreatic necrosis is feasible, well tolerated and beneficial for the patient when compared with open surgery.

Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series

BACKGROUND

Surgical treatment of necrotizing pancreatitis (NP) has undergone considerable changes during the past 2 decades. In this study, we report our experience of necrosectomy and continuous closed lavage over the past 19 years in an attempt to define changes in patient characteristics and outcome at an academic referral center.

METHODS

Among 1520 patients admitted with acute pancreatitis, 392 had NP, 285 of whom underwent operative treatment. The total series was evaluated separately for treatment period A (May 1982 until April 1993) and treatment period B (May 1993 until May 2001).

RESULTS

Intraoperative bacteriology revealed sterile necrosis in 145 and infected necrosis in 140 patients. Preoperative disease severity did not differ between the groups; however, the extent of pancreatic parenchymal necrosis was less in patients with sterile necrosis (P < .003). Postoperative complications were more frequent in infected necrosis (78%) than in sterile necrosis (61%) (P < .004), with mortality rates of 27% and 23%, respectively. The analysis of the 2 treatment periods revealed that during period B, there was a decrease in operatively treated patients with sterile necrosis (P < .0005). The preoperative systemic disease severity was significantly higher in these patients than in patients with infected necrosis.

CONCLUSIONS

Surgical treatment of NP by necrosectomy and closed lavage carries an overall mortality of 25%. Patients with sterile necrosis and early onset high disease severity may represent a distinct clinical entity in whom the optimal treatment strategy remains to be defined.

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Early and late complications after pancreatic necrosectomy

BACKGROUND

Surgery for pancreatic necrosis is associated with a high morbidity and mortality. The aim of this study was to review the incidence of early and late complications after pancreatic necrosectomy in a large contemporary series of patients.

METHODS

The clinical outcomes of 88 patients who underwent pancreatic necrosectomy between 1997 and 2003 were reviewed.

RESULTS

The median age was 55.5 (range, 18-85) years, 54 (61%) were males, 68 (77%) had primary pancreatic infection, 71 (81%) had >50% necrosis, and the median admission Acute Physiology and Chronic Health Evaluation score was 9 (range, 1-21). Median time to surgery was 31 (range, 1-161) days; 47 patients underwent minimally invasive necrosectomy and 41 open necrosectomy; 81 (92%) of patients had complications postoperatively, and 25 (28%) died. Multiorgan failure (odds ratio = 3.4, P = .05) and hemorrhage (odds ratio = 6.1, P = .03) were the only independent predictors of mortality. During a median follow-up of 28.9 months, 39 (62%) of 63 surviving patients had one or more late complications: biliary stricture in 4 (6%), pseudocyst in 5 (8%), pancreatic fistula in 8 (13%), gastrointestinal fistula in 1 (2%), delayed collections in 3 (5%), and incisional hernia in 1 (2%); intervention was required in 10 (16%) patients. Sixteen (25%) of 63 surviving patients developed exocrine insufficiency, and 19 (33%) of 58 without prior diabetes mellitus developed endocrine insufficiency.

CONCLUSIONS

Almost all patients undergoing necrosectomy developed significant early or late complications or both. Multiorgan failure and postoperative hemorrhage were independent predictors of mortality. Long-term follow-up was important because 62% developed complications, and 16% of those with complications required surgical or endoscopic intervention.

Outcome of severe acute pancreatitis

BACKGROUND

The treatment of severe acute pancreatitis has been evolving from routine operative management to nonoperative care for patients without evidence of pancreatic infection.

METHODS

Retrospective chart review of patients with severe acute pancreatitis at a single institution during a 9-year period.

RESULTS

Sixty consecutive patients had severe pancreatitis. Forty-two had pancreatic necrosis on computed axial tomography (13 infected and 29 sterile). Patients with infected necrosis and 8 with sterile necrosis had operative debridement; the remaining patients were managed without operation (n = 39). The overall mortality was 15%. Mortality was directly related to the Acute Physiology and Chronic Health Examination II and Marshall organ failure scores (P <0.001). Patients who died had a greater incidence of nosocomial infection.

CONCLUSIONS

Patients with infected pancreatic necrosis require early operative debridement, whereas those with sterile necrosis or severe pancreatitis without necrosis can usually be managed safely without surgery.

PERCUTANEOUS DRAINAGE AND NECROSECTOMY IN THE MANAGEMENT OF PANCREATIC NECROSIS

BACKGROUND

The degree of necrosis and presence of infection are the crucial determinants of the outcome in patients with pancreatic necrosis. In patients with sterile necrosis, the necrotic material can persist and subsequently results in sepsis. Some of these patients will ultimately require an operation to remove the necrotic material. Percutaneous necrosectomy has been introduced to remove this residual debris in a minimally invasive way.

METHODS

We retrospectively reviewed all patients with pancreatic necrosis who had percutaneous drainage (PCD) performed. Percutaneous pancreatic necrosectomy (PCPN) was done for those patients whose necrotic cavity failed to resolve.

RESULTS

Percutaneous drainage was performed in eight patients, four with evidence of infection by the positive culture in the aspirate. In three of them, the necrotic cavity completely resolved after drainage. Percutaneous necrosectomy was performed in another three patients through the tract placed by the radiologist and another one through a sinus tract after an operation. The necrotic cavity in three of them completely resolved after percutaneous necrosectomy.

CONCLUSION

Those patients who had 'organized necrosis' after the acute episode of pancreatitis could receive benefit from percutaneous necrosectomy. The persistent symptoms could be alleviated after the removal of the residual necrotic material. It could also be useful after an open surgery to remove any residual devitalized tissue.

Management of the critically ill patient with severe acute pancreatitis

OBJECTIVE

Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this consensus statement is to provide recommendations regarding the management of the critically ill patient with severe acute pancreatitis (SAP).

DATA SOURCES AND METHODS

An international consensus conference was held in April 2004 to develop recommendations for the management of the critically ill patient with SAP. Evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature to address specific questions concerning the management of patients with severe acute pancreatitis.

DATA SYNTHESIS

There were a total of 23 recommendations developed to provide guidance to critical care clinicians caring for the patient with SAP. Topics addressed were as follows. 1) When should the patient admitted with acute pancreatitis be monitored in an ICU or stepdown unit? 2) Should patients with severe acute pancreatitis receive prophylactic antibiotics? 3) What is the optimal mode and timing of nutritional support for the patient with SAP? 4) What are the indications for surgery in acute pancreatitis, what is the optimal timing for intervention, and what are the roles for less invasive approaches including percutaneous drainage and laparoscopy? 5) Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? 6) Is there a role for therapy targeting the inflammatory response in the patient with SAP? Some of the recommendations included a recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis. The jury also recommended against pancreatic debridement or drainage for sterile necrosis, limiting debridement or drainage to those with infected pancreatic necrosis and/or abscess confirmed by radiologic evidence of gas or results or fine needle aspirate. Furthermore, the jury recommended that whenever possible, operative necrosectomy and/or drainage be delayed at least 2-3 wk to allow for demarcation of the necrotic pancreas.

CONCLUSIONS

This consensus statement provides 23 different recommendations concerning the management of patients with SAP. These recommendations differ in several ways from previous recommendations because of the release of recent data concerning the management of these patients and also because of the focus on the critically ill patient. There are a number of important questions that could not be answered using an evidence-based approach, and areas in need of further research were identified.

Perioperative factors determine outcome after surgery for severe acute pancreatitis

Introduction

There is evidence that postponing surgery in critically ill patients with severe acute pancreatitis (SAP) leads to improved survival, but previous reports included patients with both sterile and infected pancreatic necrosis who were operated on for various indications and with different degrees of organ dysfunction at the moment of surgery, which might be an important bias. The objective of this study is to analyze the impact of timing of surgery and perioperative factors (severity of organ dysfunction and microbiological status of the necrosis) on mortality in intensive care unit (ICU) patients undergoing surgery for SAP.

Methods

We retrospectively (January 1994 to March 2003) analyzed patients admitted to the ICU with SAP. Of 124 patients, 56 were treated surgically; these are the subject of this analysis. We recorded demographic characteristics and predictors of mortality at admission, timing of and indications for surgery, and outcome. We also studied the microbiological status of the necrosis and organ dysfunction at the moment of surgery.

Results

Patients' characteristics were comparable in patients undergoing early and late surgery, and there was a trend toward a higher mortality in patients who underwent early surgery (55% versus 29%, P = 0.06). In univariate analysis, patients who died were older, had higher organ dysfunction scores at the day of surgery, and had sterile necrosis more often; there was a trend toward earlier surgery in these patients. Logistic regression analysis showed that only age, organ dysfunction at the moment of surgery, and the presence of sterile necrosis were independent predictors of mortality.

Conclusions

In this cohort of critically ill patients operated on for SAP, there was a trend toward higher mortality in patients operated on early in the course of the disease, but in multivariate analysis, only greater age, severity of organ dysfunction at the moment of surgery, and the presence of sterile necrosis, but not the timing of the surgical intervention, were independently associated with an increased risk for mortality.

Source control in the management of severe sepsis and septic shock: An evidence-based review

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for source control in the management of severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and to improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591.

CONCLUSION

Source control represents a key component of success in therapy of sepsis. It includes drainage of infected fluids, debridement of infected soft tissues, removal of infected devices or foreign bodies, and finally, definite measures to correct anatomic derangement resulting in ongoing microbial contamination and to restore optimal function. Although highly logical, since source control is the best way to reduce quickly the bacterial inoculum, most recommendations are, however, graded as D or E due to the difficulty to perform appropriate randomized clinical trials in this respect. Appropriate source control should be part of the systematic checklist we have to keep in mind in setting up the therapeutic strategy in sepsis.

Incidence, management and recurrence rate of acute pancreatitis

BACKGROUND

Acute pancreatitis is a common condition that is still associated with substantial morbidity and mortality rates. Management, outcome and recurrence rate in acute pancreatitis in a clinical setting using a conservative management approach are described.

METHODS

A total of 1376 consecutive cases representing 2211 hospitalizations due to acute pancreatitis treated at the Dept. of Surgery, Lund University Hospital, Lund, were reviewed retrospectively. Management, outcome and recurrence rate were recorded.

RESULTS

Incidence, including recurrences, was 300 per million per year; 21% of patients had recurrent (> or =2) attacks. In relapsing disease, two-thirds of patients had the first attack within 3 months. Mortality decreased over the period studied, but overall it was 4.2%; mortality in relapsing attacks was 2.5%, related to multiple organ dysfunction (MODS) in 67% and occurring within the first week in 36%.

CONCLUSIONS

Despite a conservative approach in the management of acute pancreatitis, mortality is still substantial, frequently occurs early after admission, is associated with MODS and is also seen in relapsing disease. Early cholecystectomy and bile duct clearance could decrease recurrent attacks of biliary pancreatitis.

Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis

BACKGROUND

In predicted severe acute pancreatitis, many patients develop organ failure and recover without local complications, and mortality is only 14-30%. It has been suggested that half of patients with progressive early organ failure may die, but there are no data to relate death or local complications to duration of early (week 1) organ failure.

AIMS

To determine mortality rates in patients with transient (<48 hours) and persistent (>48 hours) early organ failure and to show whether persistent organ failure predicts death or local complications.

PATIENTS

A total of 290 patients with predicted severe acute pancreatitis previously studied in a trial of lexipafant, recruited from 78 hospitals through 18 centres in the UK.

METHOD

Manual review of trial database to determine: the presence of organ failure (Marshall score > or =2) on each of the first seven days in hospital, duration of organ failure, and outcome of pancreatitis (death, complications by Atlanta criteria).

RESULTS

Early organ failure was present in 174 (60%) patients. After transient organ failure (n = 71), outcome was good: one death and 29% local complications. Persistent organ failure (n = 103) was followed by 36 deaths and 77% local complications, irrespective of onset of organ failure on admission or later during the first week.

CONCLUSION

Duration of organ failure during the first week of predicted severe acute pancreatitis is strongly associated with the risk of death or local complications. Resolution of organ failure within 48 hours suggests a good prognosis; persistent organ failure is a marker for subsequent death or local complications.

Imaging and Percutaneous Management of Acute Complicated Pancreatitis

Acute pancreatitis varies from a mild, self-limited disease to one with significant morbidity and mortality in its most severe forms. While clinical criteria abound, imaging has become indispensable to diagnose the extent of the disease and its complications, as well as to guide and monitor therapy. Percutaneous interventional techniques offer options that can be life-saving, surgery-sparing or important adjuncts to operation. Close cooperation and communication between the surgeon, gastroenterologist and interventional radiologist enhance the likelihood of successful patient care.

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.

Intravenous n-acetylcysteine, ascorbic acid and selenium-based anti-oxidant therapy in severe acute pancreatitis

BACKGROUND

To observe outcome in a cohort of patients with severe acute pancreatitis receiving multiple anti-oxidant therapy.

METHODS

An observational study was carried out in 46 consecutive patients with acute pancreatitis fulfilling current Atlanta consensus criteria for severe disease. All patients received multiple anti-oxidant therapy based on intravenous selenium, N-acetylcysteine and ascorbic acid plus beta-carotene and alpha-tocopherol delivered via nasogastric tube. Principal outcomes were the effect of anti-oxidant supplementation on anti-oxidant levels, morbidity and mortality in patients on anti-oxidant therapy, case-control analysis of observed survival compared to predicted survival derived from logistic organ dysfunction score (LODS), logistic regression analysis of factors influencing outcome and side effect profile of anti-oxidant therapy.

RESULTS

Paired baseline and post-supplementation data were available for 25 patients and revealed that anti-oxidant supplementation restored vitamin C (P = 0.003) and selenium (P = 0.028) toward normal. In univariate survival analysis, patient survival to discharge was best predicted by admission APACHE-II score with relative risk of death increasing 12.6% for each unit increase (95% CI 6.0% to 19.6%). The mean LODS calculated on admission to hospital was 3.7 (standard error of the mean 4.1) giving a predicted mortality for the cohort of 21%. The observed in-hospital mortality was 43%.

CONCLUSIONS

Case-control analyses do not appear to demonstrate any benefit from the multiple anti-oxidant combination of selenium, N-acetylcysteine and ascorbic acid in severe acute pancreatitis.

Early antibiotic treatment (prophylaxis) of septic complications in severe acute necrotizing pancreatitis: a prospective, randomized, multicenter study comparing two regimens with imipenem-cilastatin

OBJECTIVE

We compared two imipenem regimens for prevention of septic complications in patients with severe acute necrotizing pancreatitis (ANP).

DESIGN AND SETTING

Prospective, randomized open clinical trial involving intensive care units of 14 Spanish Hospitals.

PARTICIPANTS

92 patients with ANP.

INTERVENTIONS

Imipenem/cilastatin was administered at 500 mg four times daily starting at the time of diagnosis of ANP, within the first 96 h from the onset of symptoms. Patients were randomized to receive antibiotic prophylaxis either for 14 days (group 1) or at least for 14 days and as long as major systemic complications of the disease persisted (group 2).

RESULTS

Antibiotic was maintained in group 2 for 19.7+/-10.9 days. The incidence of infected pancreatic necrosis, pancreatic abscess, and extrapancreatic infections was 11%, 17%, and 28% in group 1 and 17.4%, 13%, and 35% in group 2 (n.s.). Pancreatic or extrapancreatic infection by Candida albicans occurred in 7% and 22% of patients. Global mortality was 18.5% (10.9% secondary to septic complications), without differences between groups. In patients with persisting systemic complications at day 14 mortality was almost always secondary to septic complications and decreased from 25% (group 1) to 8.8% (group 2) by maintaining antibiotic prophylaxis.

CONCLUSIONS

Compared to a 14-day imipenem prophylaxis, a longer antibiotic administration in patients with ANP is not associated with a reduction in the incidence of septic complications of the disease. However, prolonged imipenem administration in patients with persisting systemic complications tends to reduce mortality in ANP compared to a 14-days regimen.

Intraabdominal sepsis: newer interventional and antimicrobial therapies for infected necrotizing pancreatitis

PURPOSE OF REVIEW

Recent advances in interventional techniques and antimicrobial therapy have significantly affected the morbidity and mortality of infected pancreatic necrosis. This review describes elements of this progress.

RECENT FINDINGS

Operative management of infected pancreatic necrosis has consisted of formal laparotomy and debridement of the pancreatic necrosis/infection. Typically, the abdominal wound has been left open and the pancreatic bed has been reexplored at frequent intervals. This staged approach has been replaced by a single definitive operative procedure. More recently, laparoscopic techniques have been used, and provide the possibility of substantially lessened morbidity. The benefits of antimicrobial prophylaxis, typically with carbapenems, have been demonstrated in several clinical trials. The use of such broad-spectrum therapy has complicated the antimicrobial management of prophylaxis failures. A resistant flora is encountered in such patients, including gram-positive cocci, yeast, and gram-negative bacilli. This has been shown to mandate empiric therapy with combination regimens based on agents not used for prophylaxis.

SUMMARY

These findings recommend the practice of routine antibacterial prophylaxis with systemic agents. Patients receiving such treatment should be monitored for colonization by yeast; surveillance cultures do not appear to be necessary because these critically ill patients have an inflammatory disease and frequently experience temperature elevations warranting cultures to rule out infection. If infection is documented by aspiration or intervention, aggressive antimicrobial therapy directed at organisms identified by Gram stain should be started. Classes of antimicrobial agents other than those used for prophylaxis should be used.

Laparoscopic management of severe acute pancreatitis

INTRODUCTION

Severe acute pancreatitis (SAP) remains a serious disease state difficult to manage. Laparoscopic surgery represents a relatively new solution to this problem. This study was aimed to investigate the feasibility of laparoscopic treatment of SAP and the selection of laparoscopic procedures in various stages of SAP according to different pathologic alterations.

METHODS

Thirteen patients, 9 men and 4 women with an average age of 46 years old, were diagnosed with SAP. Laparoscopic necrosectomy followed by external drainage were performed on 7 patients with massive fluid collections and/or infected necrosis in acute reaction phase of SAP. For 2 cases in subacute phase characterized by fresh-formed adhesions and encapsulation, laparoscopic intracavitary debridement experienced difficulty. For the other 4 patients in late phase with well-defined pancreatic or peripancreatic pseudocyst/abscess, ultrasound-guided, directly visualized laparoscopic intracavitary debridement, and external drainage were carried out with ease and efficiency.

RESULTS

Laparoscopic procedures were accomplished successfully on 12 patients (92.3%), except for 1 conversion (7.7%) to open laparotomy owing to poor exposure and hard maneuvers in subacute phase. There was no mortality in this group. Patients were witnessed to have accelerated recovery following laparoscopic surgery.

CONCLUSION

Laparoscopic technique offers new hope for the treatment of SAP. It is recommended as a feasible, effective, and less traumatic therapeutic means on condition that the strategy of individualization is followed.

Conservative management of infected necrosis complicating severe acute pancreatitis

OBJECTIVES

Patients with severe necrotizing pancreatitis are at risk for infection, a major cause of morbidity and mortality. Most patients with infected pancreatic tissue require surgical intervention (necrosectomy), which is associated with high morbidity and mortality. A subset of these patients can be managed successfully with conservative management combined with prolonged courses of antibiotics.

METHODS

Three cases of severe acute pancreatitis seen at our institution are described, in which the patients developed aspirate-proven pancreatic infections. The patients were nonetheless stable from a clinical standpoint and were treated with long courses of antibiotics known to penetrate the pancreas; emergent surgery was deferred.

RESULTS

In two patients, surgery was completely avoided, with good clinical outcome. In the third patient, elective surgery was undertaken 12 wk after the episode of acute pancreatitis, to perform necrosectomy on organized pancreatic necrosis and to evaluate the patient's biliary tree. There were no postoperative complications.

CONCLUSIONS

A subset of patients with severe acute pancreatitis complicated by infection can be successfully managed with long term antibiotics and other supportive measures. High risk necrosectomy can, in some instances, be delayed or avoided entirely.