Acute necrotizing pancreatitis: treatment strategy according to the status of infection

Percutaneous management of pancreatic abscesses: long term results in a single center

BACKGROUND

Several authors consider that surgical intervention is the gold standard for treatment of pancreatic abscesses. Recently, considerable interest has been generated in the minimally invasive management of pancreatic abscess with mixed results reported in the literature.

AIM

To evaluate the efficacy of percutaneous aspiration and/or drainage for patients with pancreatic abscesses.

METHODS

We performed a retrospective analysis of 62 patients with 87 pancreatic abscesses treated by percutaneous management from 1989 to 2009. All patients received appropriate antibiotic therapy. Patients with pancreatic abscess <50mm in diameter were initially treated by ultrasound-guided percutaneous needle aspiration (PNA) and those with abscess ≥50mm were initially treated by ultrasound-guided percutaneous catheter drainage (PCD). Surgery was planned only when there was no clinical improvement after the initial percutaneous treatment. Primary outcome was conversion rate to surgery.

RESULTS

Two patients (3.2%) received supportive treatment only and one of them died. PNA was performed in 16 patients (25.8%), and 8 of them required PCD because of recurrence of abscess. In 44 patients (70.1%), PCD was performed initially. PCD was performed twice in 6 patients and 3 times in 2 patients. There were 5 patients converted to surgery (8.1%) and one of them died. Medians (interquartile ranges) of hospital stay and catheter dwell-time were 17 (12-26) and 12 (9-21) days, respectively. There were no complications related to the procedure.

CONCLUSIONS

Percutaneous aspiration and/or drainage are effective and safe for the treatment of pancreatic abscesses.

Nutritional support in acute and chronic pancreatitis

Nutritional support can have a significant beneficial impact on the course of moderate to severe acute pancreatitis. Enteral nutrition is preferred, with emphasis on establishment of jejunal access; however, parenteral nutrition can also be of value if intestinal failure is present. Early initiation of nutritional support is critical, with benefits decreasing rapidly if begun after 48 hours from admission. Severe malnutrition in chronic pancreatitis can be avoided or treated with dietary modifications or enteral nutrition.

Melittin inhibits cerulein-induced acute pancreatitis via inhibition of the JNK pathway

The major compound of bee venom, melittin, has been used as an anti-inflammatory reagent for decades. However, the potential of melittin to ameliorate acute pancreatitis (AP) is unknown. Our aim was to investigate the effect of melittin on cerulein-induced AP. Pre- and post-treatment with melittin inhibited histological changes in the pancreas and lungs during cerulein-induced AP. Pancreatic weight/body weight ratios; digestive enzymes, including amylase and lipase; serum and pancreatic cytokine expression; and myeloperoxidase activity were decreased. In addition, treatment with melittin inhibited the activation of c-Jun NH(2)-terminal protein kinase (JNK) in the pancreas during cerulein-induced pancreatitis. In accordance with the results of in vivo experiments, melittin reduced cerulein-induced cell death, and production of inflammatory cytokines. In conclusion, our results suggest that melittin attenuated AP and AP-associated lung injury through the inhibition of JNK activation.

Intra-abdominal pressure and abdominal perfusion pressure: which is a better marker of severity in patients with severe acute pancreatitis

BACKGROUND

Intra-abdominal hypertension is common in patients with severe acute pancreatitis. The aim of this study was to assess the clinical relevance of intra-abdominal pressure and abdominal perfusion pressure in the first 72 h after admission during severe acute pancreatitis.

METHODS

From January 2009 to February 2011, 50 patients admitted for severe acute pancreatitis were included in this prospective, observational study. The intra-abdominal pressure and abdominal perfusion pressure level were repeatedly measured every 12 h during the first 72 h. The maximum and the mean values of intra-abdominal pressure and the minimum and mean values of abdominal perfusion pressure were used for analysis.

RESULTS

Both the maximum and mean levels of intra-abdominal pressure were significantly different between patients with or without kinds of clinical variables. But for abdominal perfusion pressure, difference could only be detected in terms of need of vasoactive drugs. Besides that, different from abdominal perfusion pressure, intra-abdominal pressure is associated with high incidence rates of MODS and secondary infection.

CONCLUSION

Compared with abdominal perfusion pressure, intra-abdominal pressure is much more valuable as an early marker of the evolution and complications of severe acute pancreatitis.

Parenteral nutrition versus enteral nutrition in severe acute pancreatitis

PURPOSE

To compare the effect of parenteral versus enteral nutritional support in severe acute pancreatitis, with respect to efficacy, safety, morbidity, mortality and length of hospitalization.

METHODS

The study was comprised of 31 patients, divided into a parenteral group (n=16) and an enteral group (n=15), who met severity criteria for abdominal tomography (Balthazar classes C, D, and E). The patients were compared by demographics, disease etiology, antibiotic prophylaxis, use or not of somatostatin, nutritional support, complications and disease progression.

RESULTS

There was no statistical difference in the average duration of nutritional support, somatostatin, or antibiotics in the two groups. Imipenem was the drug of choice for prophylaxis of pancreatic infections in both groups. More complications occurred in the parenteral group, although the difference was not statistically significant (p=0.10). Infectious complications, such as catheter sepsis and infections of the pancreatic tissue, were significantly more frequent in the parenteral group (p=0.006). There was no difference in average length of hospitalization in the two groups. There were three deaths in the parenteral group and none in the enteral group.

CONCLUSION

Enteral nutritional support is associated with fewer septic complications compared to parenteral nutritional support.

Severe acute pancreatitis: advances and insights in assessment of severity and management

The patients with acute pancreatitis are at risk to develop different complications from ongoing pancreatic inflammation. Often, there is no correlation between the degree of structural damage to pancreas and clinical manifestation of the disease. The effectiveness of any treatment is related to the ability to predict severity accurately, but there is no ideal predictive system or biochemical marker. Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis. The use of multiparametric criteria and the evaluation of severity index permit us to select high-risk patients. Furthermore, contrast-enhanced computed tomographic scanning and contrast-enhanced MRI play an important role in severity assessment. The adoption of multiparametric criteria proposed together with morphological evaluation consents the formulation of a discreetly reliable prognosis on the evolution of the disease a few days from onset.

Endoscopic necrosectomy of pancreatic necrosis: a systematic review

AIM

To review the current status of the novel technique of endoscopic necrosectomy in the management of pancreatic necrosis after acute pancreatitis.

METHODS

Studies were identified by searching Medline, PubMed and Embase databases for articles from January 1990 to December 2009 using the keywords "acute pancreatitis", "pancreatic necrosis" and "endoscopy". Additional papers were identified by a manual search of the references from the key articles. Case series of fewer than five patients and case reports were excluded.

RESULTS

Indications, techniques and outcomes of endoscopic necrosectomy were analysed. There were no randomised controlled trials identified. Ten case series were included in this analysis. There were a total of more than 1,100 endoscopic necrosectomy procedures in 260 patients with pancreatic necrosis. One hundred fifty-five were proven to be infected necrosis on culture. The overall mortality rate was 5%. The mean procedure-related morbidity rate was 27%. The rate of complete resolution of pancreatic necrosis with the endoscopic method alone was 76%.

CONCLUSIONS

Endoscopic necrosectomy is a safe and effective treatment option in selected patients with pancreatic necrosis after acute pancreatitis. Future studies will be required to further define the selection criteria and the techniques for the endoscopic procedure.

A meta-analysis of enteral nutrition and total parenteral nutrition in patients with acute pancreatitis

Objective. To analyze the effect of total parenteral nutrition (TPN) and enteral nutrition (EN) in patients with acute pancreatitis. Methods. Randomized controlled trials of TPN and EN in patients with acute pancreatitis were searched in NCBI and CBM databases and The Cochrane Controlled Trials Register. Six studies were enrolled into the analysis, and the details about the trial designs, characters of the subjects, results of the studies were reviewed by two independent authors and analyzed by STATA 11.0 software. Results. Compared with TPN, EN was associated with a significantly lower incidence of pancreatic infection complications (RR = 0.556, 95% CI 0.436∼0.709, P = .000), MOF (RR = 0.395, 95% CI 0.272∼0.573, P = .003), surgical interventions (RR = 0.556, 95% CI 0.436∼0.709, P = .000), and mortality (RR = 0.426, 95% CI 0.238∼0.764, P = .167). There was no statistic significance in non-pancreatitis-related complications (RR = 0.853, 95% CI 0.490∼1.483, P = .017). However, EN had a significantly higher incidence of non-infection-related complications (RR = 2.697, 95% CI 1.947∼3.735, P = .994). Conclusion. EN could be the preferred nutrition feeding method in patients with acute pancreatitis.

Step-up approach to infected necrotising pancreatitis: a 20-year experience of percutaneous drainage in a single centre

AIM

To evaluate the efficacy of step-up approach to infected necrotising pancreatitis.

METHODS

Retrospective analysis of 86 patients treated by step-up approach from 1989 to 2009. Infection was confirmed by examination of aspirated material or by presence of free pancreatic gas at contrast-enhanced computed tomography. Conservative treatment was initially attempted in all patients; percutaneous catheter drainage was performed when conservative therapy failed; surgery was planned only if no clinical improvement was observed. Primary outcome was mortality.

RESULTS

Fifteen patients (17.4%) were successfully treated with conservative treatment only. Percutaneous catheter drainage was performed in 69 (80.2%). Eight patients (9.3%) died, two at week 1 without drainage or surgery and six after percutaneous catheter drainage and surgery. Eleven patients were converted to surgery (12.8%). Organ failure occurred in 59/86 (68.6%) and multiorgan failure in 25/86 (29.1%). Median (interquartile ranges) hospital stay and catheter dwell times were 13 (9-47) and 15 (7-34) days, respectively. There were 2.61 catheter problems and 1.68 catheter changes per patient.

CONCLUSIONS

The step-up approach is an effective and safe strategy for the treatment of infected necrotising pancreatitis. Percutaneous drainage can avert the need for surgery in the majority of patients.

Fungal infections in severe acute pancreatitis

Severe acute pancreatitis (SAP) is associated with significant morbidity and mortality. The majority of deaths related to SAP are the result of infectious complications. Although bacterial infections are most commonly encountered, fungal infections are increasingly being recognized. Candida is the most common fungal infection. The occurrence of fungal infection in patients with acute pancreatitis adversely affects the clinical course, leading to a higher incidence of systemic complications, and possibly mortality as well. Important risk factors for fungal infection in patients with acute pancreatitis include broad-spectrum antibiotics, prolonged hospitalization and surgical/endoscopic interventions, use of total parenteral nutrition, and mechanical ventilation. Patients with higher severity of pancreatitis are at a greater risk. The pathogenesis of fungal infection in patients with acute pancreatitis is multifactorial. Translocation of microorganisms across the gut epithelium, lymphocyte dysfunction, and the virulence of the invading microorganisms play important roles. Histological demonstration of fungi remains the gold standard of diagnosis, but a positive biopsy is rarely obtained. The role of biomarkers in the diagnosis is being investigated. As early diagnosis and treatment can lead to improved outcome, a high index of suspicion is required for prompt diagnosis. Limiting the use of broad-spectrum antibiotics, early introduction of enteral nutrition, and timely change of vascular catheters are important preventive strategies. The role of antifungal prophylaxis remains controversial. Surgical necrosectomy with antifungal therapy is the most widely used treatment approach. Clinical trials on antifungal prophylaxis are needed, and indications for surgical intervention need to be clearly defined.

Piperine ameliorates the severity of cerulein-induced acute pancreatitis by inhibiting the activation of mitogen activated protein kinases

Piperine is a phenolic component of black pepper (Piper nigrum) and long pepper (Piper longum), fruits used in traditional Asian medicine. Our previous study showed that piperine inhibits lipopolysaccharide-induced inflammatory responses. In this study, we investigated whether piperine reduces the severity of cerulein-induced acute pancreatitis (AP). Administration of piperine reduced histologic damage and myeloperoxidase (MPO) activity in the pancreas and ameliorated many of the examined laboratory parameters, including the pancreatic weight (PW) to body weight (BW) ratio, as well as serum levels of amylase and lipase and trypsin activity. Furthermore, piperine pretreatment reduced the production of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 during cerulein-induced AP. In accordance with in vivo results, piperine reduced cell death, amylase and lipase activity, and cytokine production in isolated cerulein-treated pancreatic acinar cells. In addition, piperine inhibited the activation of mitogen-activated protein kinases (MAPKs). These findings suggest that the anti-inflammatory effect of piperine in cerulein-induced AP is mediated by inhibiting the activation of MAPKs. Thus, piperine may have a protective effect against AP.

Immune dysregulation in patients with severe acute pancreatitis

To investigate patients with severe acute pancreatitis (SAP) by dynamic levels of pro-/anti-inflammatory cytokines and endotoxin (ET) in plasma and the relationship between immunity and infection, organ dysfunction. Seventy-two patients with SAP were recruited. The ET, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-10 (IL-10), and interleukin-4 (IL-4) were determined on admission and days 3, 7, and 14. For comparison, patients were analyzed through infection group versus non-infection group, multiple organ dysfunction syndrome (MODS) group versus non-MODS group. There were sixteen patients with secondary infection, twenty-two with MODS, and nine deaths. The infection group had higher levels of ET than the non-infection group on days 3 and 7. The dynamic cytokine levels of patients in the MODS group were unanimous with those outcomes in the infection group. The levels of cytokines in the infection group were different from the non-infection group, with more levels of TNF-α, IL-6 on days 3 and 7 and less on days 14, and more levels of IL-10, IL-4 on days 7 and 14. The levels of TNF-α, IL-6 in the MODS group were different from the non-MODS group, with more levels on days 3 and 7, and less levels on days 14. Immune dysregulation may play an important role in infection and organ dysfunction for patients with SAP.

Protease inhibitors for preventing complications associated with ERCP: an updated meta-analysis

BACKGROUND AND OBJECTIVES

The prophylactic use of protease inhibitors in patients undergoing ERCP is still controversial. Our purpose was to evaluate the efficacy of protease inhibitors in preventing ERCP-associated complications.

DESIGN AND SETTING

Meta-analysis; randomized trials that evaluated the efficacy of protease inhibitors were identified.

PATIENTS

A total of 4966 patients were evaluated.

MAIN OUTCOME MEASUREMENTS

ERCP-associated pancreatitis, hyperamylasemia, abdominal pain, and death.

RESULTS

Eighteen studies (19 cohorts) met the inclusion criteria. Overall results for protease inhibitors showed a significant but small risk reduction in ERCP-associated pancreatitis (pooled risk difference [RD]: -0.029; 95% CI, -0.051 to -0.008 and the number needed to treat, 34.5; 95% CI, 19.6-125). Subgroup analysis in 8 high-quality studies showed a borderline significant efficacy (pooled RD, -0.027; 95% CI, -0.051 to -0.004). Subgroup analysis in 8 gabexate studies did not show significant efficacy (pooled RD, -0.030; 95% CI, -0.062 to 0.003). Subgroup analysis in 5 ulinastatin studies was significant (pooled RD, -0.035; 95% CI, -0.063 to -0.006). Two high-quality studies on ulinastatin yielded nonsignificant results. Analyses for the other outcomes were all nonsignificant. Sensitivity analysis showed that the effect size and level of statistical significance were decreased with increasing study quality.

CONCLUSIONS

At present, there is no solid evidence to support the use of protease inhibitors to prevent ERCP-associated complications. Although overall and ulinastatin subgroup analyses showed a small risk reduction for pancreatitis, it seems very possible that low-quality primary studies produced a veneer of efficacy.

Minimally invasive retroperitoneal pancreatic necrosectomy

INTRODUCTION

This article describes a case series outlining the experience and results of the retroperitoneal minimally invasive pancreatic necrosectomy (MIPN) procedure performed by, or done under the supervision of, a single surgeon.

METHODS

All data of the patients who underwent MIPN from 2006 to 2008 were entered into a prospectively maintained, computerized database.

RESULTS

A total of 93 MIPN procedures were performed on 32 patients. All patients had severe acute pancreatitis. The median number of MIPN procedures per patient was 3. Only 6 patients needed intensive care unit (ICU) admission after MIPN. There were 15 complications, which included bleeding requiring transfusion (n = 3), bowel fistulae (n = 7), thromboembolic events (n = 2) and acute myocardial infarction (n = 3). Four patients died after the procedure (13%); 1 died of ongoing multiorgan failure in spite of the MIPN. Four patients developed pancreatic pseudocysts within the follow-up period of 2 years. Three of these patients required intervention.

CONCLUSION

This case series demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The ICU dependency after the procedure is minimal. As seen in this series, multiple MIPNs may be needed to eradicate the necrosis satisfactorily. and IAP.

Effects of enteral immunonutrition on the maintenance of gut barrier function and immune function in pigs with severe acute pancreatitis

BACKGROUND

This study evaluated the effects of enteral immunonutrition (EIN) supplemented with glutamine, arginine, and probiotics on gut barrier function and immune function in pigs with severe acute pancreatitis (SAP).

METHODS

The model was induced by retrograde injection of 5% sodium taurocholate and trypsin via the pancreatic duct. After induction of SAP, 18 pigs were randomly divided into 3 groups, in which either parenteral nutrition (PN), control enteral nutrition (CEN), or EIN was applied for 8 days. Serum and pancreatic fluid amylase concentration was determined. Intestinal permeability (lactulose to mannitol ratio) was measured by high-performance liquid chromatography, and plasma endotoxin was quantified by the chromogenic limulus amebocyte lysate technique. Samples of venous blood and organs were cultured using standard techniques. Pancreatitis severity and villi of ileum were scored according to histopathologic grading. Plasma T-lymphocyte subsets were measured by flow cytometry, and immunoglobulins (Igs) were determined via enzyme-linked immunosorbent assay.

RESULTS

There were no significant differences in serum and pancreatic fluid amylases concentrations or in pancreatitis severity between any 2 of the 3 groups. Compared with PN and CEN, EIN significantly decreased intestinal permeability, plasma endotoxin concentration, and the incidence and magnitudes of bacterial translocation, but increased ileal mucosal thickness, villous height, crypt depth, and percentage of normal intestinal villi. Significant differences were found in CD3+, CD4+ lymphocyte subsets, the ratio of CD4+: CD8+ lymphocyte subsets, and serum IgA and IgG, but not IgM, between any 2 of the 3 groups.

CONCLUSIONS

EIN maintained gut barrier function and immune function in pigs with SAP.

A comparison of the hospital costs of open vs. minimally invasive surgical management of necrotizing pancreatitis

BACKGROUND

Infected necrotizing pancreatitis is a major burden for both the patient and the health care system. Little is known about how hospital costs break down and how they may have shifted with the increasing use of minimally invasive techniques. The aim of this study was to analyse inpatient hospital costs associated with pancreatic necrosectomy.

METHODS

A prospective database was used to identify all patients who underwent an intervention for necrotizing pancreatitis. Costs of treatment were calculated using detailed information from the Decision Support Department. Costs for open and minimally invasive surgical modalities were compared.

RESULTS

Twelve open and 13 minimally invasive necrosectomies were performed in a cohort of 577 patients presenting over a 50-month period. One patient in each group died in hospital. Overall median stay was 3.8 days in the intensive care unit (ICU) and 44 days on the ward. The median overall treatment cost was US$ 56,674. The median largest contributors to this total were ward (26.3%), surgical personnel (22.3%) and ICU (17.0%) costs. These did not differ statistically between the two treatment modalities.

CONCLUSIONS

Pancreatic necrosectomy uses considerable health care resources. Minimally invasive techniques have not been shown to reduce costs. Any intervention that can reduce the length of hospital and, in particular, ICU stay by reducing the incidence of organ failure or by preventing secondary infection is likely to be cost-effective.

Acute pancreatitis with an emphasis on infection

Acute pancreatitis is an inflammatory disease that is mild and self-limiting in about 80% of cases. However, severe necrotizing disease still has a mortality of up to 30%. Differentiated multimodal treatment concepts are needed for these patients, including a multidisciplinary team (intensivists, gastroenterologists, interventional radiologists, and surgeons). The primary therapy is supportive. Patients with infected pancreatic necrosis who are septic undergo interventional or surgical treatment, ideally not before the fourth week after onset of symptoms. This article reviews the pathophysiologic mechanisms of acute pancreatitis and describes clinical pathways for diagnosis and management based on the current literature and guidelines.

The clinical outcome of elderly patients with acute pancreatitis is not different in spite of the different etiologies and severity

The aim of this study was to investigate the overall clinical characteristics of elderly patients with acute pancreatitis. We retrospectively evaluated 227 consecutively enrolled patients who were admitted with acute pancreatitis. The clinical features, the radiological and laboratory data and the clinical outcome were analyzed according to the age groups (≥ 65 years vs. <65 years). Among the 227 enrolled patients with acute pancreatitis, there were 85 elderly patients and 142 non-elderly. The mean age of the elderly patients was 72.3 ± 5.5 years and that of the non-elderly was 44.7 ± 11.7 (p<0.001). For the elderly patients, biliary pancreatitis was the most common cause (56.5%), but alcoholic pancreatitis was most common in the non-elderly patients (45.8%). Although the computed tomography (CT) severity index was significantly higher for the non-elderly patients (p<0.001), the acute physiology and chronic health evaluation (APACHE II) score was significantly higher for the elderly than that for the non-elderly (p<0.001). However, the duration of the hospital stay (10.3 ± 9.6 days vs. 11.9 ± 10.1 days, p=0.619) and mortality (3.5% vs. 0.7%, p=0.148) were not different between the age-groups. In our study, chronological age had no significant influence on the clinical outcome in spite of the different etiologies and severity of acute pancreatitis.

Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis

BACKGROUND

The role of percutaneous catheter drainage (PCD) in patients with (infected) necrotizing pancreatitis was evaluated.

METHODS

A systematic literature search was performed. Inclusion criteria were: consecutive cohort of patients with necrotizing pancreatitis undergoing PCD as primary treatment for peripancreatic collections; indication for PCD either (suspected) infected necrosis or symptomatic sterile pancreatic necrosis; and outcomes reported to include percentage of infected peripancreatic collections, need for additional surgical necrosectomy, complications and deaths. Exclusion criteria were: cohort of fewer than five patients; cohort included patients with chronic pancreatitis; selected subgroup of patients with acute pancreatitis studied, such as those with pseudocysts, pancreatic abscesses and/or exclusively sterile pancreatic necrosis; and cohort in which PCD was combined with another minimally invasive strategy and results for PCD alone not reported separately.

RESULTS

Eleven studies, including 384 patients, fulfilled the inclusion criteria. Only one study was a randomized controlled trial; most others were retrospective case series. Four studies reported on the presence of organ failure before PCD; this occurred in 67·2 per cent of 116 patients. Infected necrosis was proven in 271 (70·6 per cent) of 384 patients. No additional surgical necrosectomy was required after PCD in 214 (55·7 per cent) of 384 patients. Complications consisted mostly of internal and external pancreatic fistulas. The overall mortality rate was 17·4 per cent (67 of 384 patients). Nine of 11 studies reported mortality separately for patients with infected necrosis undergoing PCD; the mortality rate in this group was 15·4 per cent (27 of 175).

CONCLUSION

A considerable number of patients can be treated with PCD without the need for surgical necrosectomy.

Analysis of the delayed approach to the management of infected pancreatic necrosis

AIM: To analyze outcomes of delayed single-stage necrosectomy after early conservative management of patients with infected pancreatic necrosis (IPN) associated with severe acute pancreatitis (SAP).

METHODS: Between January 1998 and December 2009, data from patients with SAP who developed IPN and were managed by pancreatic necrosectomy were analyzed.

RESULTS: Fifty-nine of 61 pancreatic necrosectomies were performed by open surgery and 2 laparoscopically. In 55 patients, single-stage necrosectomy could be performed (90.2%). Patients underwent surgery at a median of 29 d (range 13-46 d) after diagnosis of acute pancreatitis. Sepsis and multiple organ failure accounted for the 9.8% mortality rate. Pancreatic fistulae (50.8%) predominantly accounted for the morbidity. The median hospital stay was 23 d, and the median interval for return to regular activities was 110 d.

CONCLUSION: This series supports the concept of delayed single-stage open pancreatic necrosectomy for IPN. Advances in critical care, antibiotics and interventional radiology have played complementary role in improving the outcomes.

Progress in the management of necrotizing pancreatitis

Pancreatic necrosis, a complication of severe pancreatitis, may become infected, resulting in significant morbidity and potential mortality. Infected necrosis was heretofore considered a surgical condition, and despite aggressive operative management, the mortality remained high. With a better understanding of the natural history of necrosis, established methods to diagnose infection and the increasing use of minimally invasive techniques, less aggressive therapies have been utilized with some success. The present study evaluated a step-up approach for the treatment of infected pancreatic necrosis, utilizing endoscopic and percutaneous techniques, and if ineffective, necrosectomy with a minimally invasive retroperitoneal approach. They compared this step-up approach to the standard open necrosectomy. They demonstrated that when using such an approach compared with open necrosectomy, the frequency of major complications such as organ failure, perforation, fistula or even death was significantly less than in those who received conventional open necrosectomy. Indeed, for those randomized to the step-up approach, roughly a third of the patients were successfully treated with percutaneous drainage alone. In the long-term, development of diabetes was also less frequent in those receiving less aggressive therapy. These findings, in combination with other reports, suggest that the dogma that open necrosectomy is mandatory for all patients with infected necrosis should be re-evaluated, and that less aggressive treatments as part of a multidisciplinary approach can reduce morbidity and mortality.

Targeting P-selectin in acute pancreatitis

IMPORTANCE OF THE FIELD

Acute pancreatitis (AP) is a multifactorial disorder not fully understood yet. In particular, the pathogenetic pathways promoting a severe life-threatening course of AP are the subject of ongoing investigations. P-selectin has been shown to play a central role in the complex pathophysiology in AP as well as various other inflammatory conditions.

AREAS COVERED IN THIS REVIEW

P-selectin function in AP is reviewed with focus on its dual function as a mediator of leukocyte recruitment and cell adhesion, which implies the unique effect of linking both inflammation and coagulation, especially in the progression from mild to severe necrotizing AP. Potential therapeutic aspects are discussed with regard to the clinical situation.

WHAT THE READER WILL GAIN

A better understanding of the pathogenic role of P-selectin in AP and of the rationale for a therapeutic blockade.

TAKE HOME MESSAGE

P-selectin is a glycoprotein that mediates the adhesion of activated platelets and leukocytes to the vessel wall in various inflammatory conditions. Both pathophysiological steps are closely linked and play a key role in the course of severe AP. A treatment approach by inhibition of P-selectin could be of distinct interest as a therapeutic option in severe AP.

Tumor necrosis factor-α and interleukin-10 contribute to immunoparalysis in patients with acute pancreatitis

Immunoparalysis, defined as downregulation of human leukocyte antigen-DR (HLA-DR) expression on monocytes, is strongly associated with septic complications of acute pancreatitis. However, the possible causes of this immunoparalysis have been largely unknown. A prospective case control study was performed in 54 patients with acute pancreatitis and 24 normal volunteers. HLA-DR expression on monocytes and serum cytokine levels were measured. In addition, monocytes from normal volunteers treated with tumor necrosis factor (TNF)-α in vitro were evaluated for HLA-DR expression and cytokine release. HLA-DR expression was significantly lower in patients with severe pancreatitis than in those with mild acute pancreatitis and healthy volunteers (42.28% ± 11.49% vs. 86.85% ± 14.56% vs. 93.92% ± 7.40%, p < 0.0001). Pearson correlation analysis showed that serum TNF-α and serum interleukin-10 levels were both correlated with HLA-DR expression. In addition, exogenous TNF-α could enhance IL-10 secretion from normal monocytes in a dose-response manner. In addition, TNF-α could downregulate the HLA-DR expression on monocytes even in the presence of anti-IL-10 antibodies. Therefore, both TNF-α and IL-10 contributed to the development of immunoparalysis in patients with acute pancreatitis.

Current Surgical Management of Infected Pancreatic Necrosis

Infected pancreatic necrosis (IPN) continues to be a challenging problem for the surgeon. We reviewed the experience on a hepatobiliary surgical service with patients who required operative intervention for IPN with emphasis on surgical approach, timing of surgery, and complications. Between 2002 and 2008, 21 patients underwent surgery for IPN. The initial surgical approach in these 21 patients included either direct pancreatic debridement (DPD, n = 13) or transgastric debridement using cyst-gastrostomy (CG, n = 8). Fifteen patients (71%) required only a single procedure, whereas three (14%) required two procedures and three (14%) required three procedures. The mean time from onset of pancreatitis to operation was 77 days. Patients requiring a single intervention had a longer interval from onset of pancreatitis to surgery compared with those requiring multiple interventions. When comparing CG and DPD groups, there was a longer interval from onset of pancreatitis to debridement, a lower chance of needing multiple debridements, and fewer pancreatic fistulae in the CG group. Overall survival was 95 per cent. Our results demonstrate that CG can be successfully used in select patients with IPN. Patients undergoing CG are less likely to require repeat surgical debridement and to develop pancreatic fistulae compared with patients undergoing DPD.

Surgical treatment of acute pancreatitis today

Az enyhe akut pancreatitis kezelése alapvetően konzervatív, míg súlyos esetekben a sebészi kezelésnek jelentős szerepe van. Módszer: A szerzők az utóbbi 10 évben megjelent, a műtét kérdéseit taglaló közlemények alapján elemzik a sebészi kezelés indikációit, időzítését és a műtét technikai kérdéseit. Eredmények/következtetések: A steril pancreasnecrosis csak ritkán, a szeptikus necrosis azonban műtéti indikációt képez, ha a konzervatív kezelés eredménytelen. A terápiarezisztens sokszervi elégtelenség, a súlyos hasi kompartmentszindróma és egyéb sebészi szövődmény, mint a vérzés, perforáció is műtéti beavatkozást tesz szükségessé. Pancreatitist okozó epekövesség talaján kialakult cholestasis esetén sürgős endoszkópos sphincterotomia és később cholecystectomia javasolt. Pancreasnecrosis esetén a műtét ideális időpontja a betegség kezdetétől számított 21. nap utánra tehető, mivel a „korai” műtétek szövődmény- és halálozási aránya magas. Fontos a gondos necrectomia, amelynek a retrocolicus és retroduodenalis terekre is ki kell terjednie. A nyitott has kezelésének több a szövődménye, ezért csak válogatott esetekben javasolják. A műtétet posztoperatív bursa omentalis lavage-zsal érdemes kiegészíteni. Orv. Hetil., 2010, 41, 1697–1701.

Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis

BACKGROUND & AIMS

There is no consistency between the individual studies in the literature on whether organ failure (OF) or infected pancreatic necrosis (IPN) is the main determinant of severity in acute pancreatitis. We aimed to statistically aggregate the available data and determine the pooled influence of OF and IPN on mortality in patients with acute pancreatitis.

METHODS

The search for relevant observational studies was undertaken in the MEDLINE, EMBASE, and Scopus electronic databases, as well as in the proceedings of major gastroenterology meetings. The summary estimates are presented as relative risk (RR) and 95% confidence interval (CI).

RESULTS

Fourteen studies comprising 1478 patients with acute pancreatitis were meta-analyzed. A total of 600 patients developed OF and 179 of them died (mortality, 30%); 314 patients developed IPN and 102 of them died (mortality, 32%). In a stratified analysis, patients with OF and IPN had a significantly higher risk of death in comparison with patients with OF and no IPN (RR = 1.94; 95% CI: 1.32-2.85; P = .0007) and in comparison with patients with IPN and no OF (RR = 2.65; 95% CI: 1.30-5.40; P = .0007).

CONCLUSIONS

In patients with acute pancreatitis, the absolute influence of OF and IPN on mortality is comparable and thus the presence of either indicates severe disease. The relative risk of mortality doubles when OF and IPN are both present and indicates extremely severe disease or critical acute pancreatitis.

Imaging of acute pancreatitis: prognostic value of computed tomographic findings

Although most cases of acute pancreatitis are uncomplicated and resolve spontaneously, the presence of complications has significant prognostic importance. Necrosis, hemorrhage, and infection convey up to 25%, 52%, and 80% mortality, respectively. Other complications such as pseudocyst formation, pseudoaneurysm formation, or venous thrombosis increase morbidity and mortality to a lesser degree.We review the computed tomographic findings of complications associated with acute pancreatitis with emphasis on their prognostic significance and impact on clinical management.

Bacterial translocation and infected pancreatic necrosis in acute necrotizing pancreatitis derives from small bowel rather than from colon

BACKGROUND

The clinical course of acute necrotizing pancreatitis (ANP) is determined by the superinfection of pancreatic necrosis. To date, the pathophysiology of the underlying bacterial translocation is poorly understood. The present study investigated the bacterial source of translocation.

METHODS

A terminal loop ileostomy was applied in rats. Selective digestive decontamination (SDD) of either the small bowel or the colon was performed. After 3 days of SDD, severe ANP was induced. At 24 hours, bacterial translocation was assessed by cultures of bowel mucosa, mesenteric lymph nodes, and pancreas using a scoring system (0-4).

RESULTS

Without SDD, pancreatic infection was present in all cases with an average score of 2.67. Colon SDD reduced pancreatic superinfection to 1.67 (not significant). SDD of the small bowel significantly reduced superinfection to 1.0 (P < .005).

CONCLUSIONS

Bacterial translocation from the colon is less frequent than translocation from the small bowel. Thus, the small bowel seems to be the major source of enteral bacteria in infected pancreatic necrosis.

Pancreatite necro-hemorrágica: atualização e momento de operar

INTRODUÇÃO: A pancreatite necro-hemorrágica representa a variante mais grave do espectro de apresentações clínicas que podem compor o quadro da pancreatite aguda. Embora já conhecida há muitos séculos, inúmeras questões permanecem em aberto acerca dessa entidade e o número de trabalhos sobre o assunto publicados nos últimos anos tem sido muito expressivo. MÉTODO: Foi realizada ampla pesquisa na literatura, com especial atenção aos artigos publicados nos últimos três anos e indexados ao PubMed. Foram utilizados os seguintes descritores de forma cruzada: pancreatitis, surgical procedures; necrosis. A pesquisa inicial evidenciou cerca de 13.000 artigos, sendo avaliados os mais relevantes dos últimos três anos além de artigos mais antigos, considerados "clássicos" sobre o assunto e que, portanto, não poderiam deixar de ser citados. CONCLUSÃO: O tratamento da pancreatite aguda envolve um grande número de questões, dentre as quais as mais importantes estão relacionadas ao manejo da antibioticoterapia, tipo de dieta empregada e as questões relacionadas ao manejo da necrose infectada. Em especial, mudanças radicais foram implementadas nos últimos anos sobre todos esses tópicos, e uma atualização constante deve ser obrigatoriamente buscada pelos profissionais envolvidos no tratamento dessa doença.

Open pancreatic necrosectomy in the multidisciplinary management of postinflammatory necrosis

OBJECTIVE

To examine clinical outcome in a consecutive cohort of patients undergoing open necrosectomy for postinflammatory necrosis.

BACKGROUND INFORMATION

The last decade has witnessed major developments in the surgical management of pancreatic necrosis. Minimally invasive approaches have become established. However, there are limited data from contemporary open necrosectomy, in particular where multidisciplinary care and aggressive interventional radiology are used. This report provides data on outcome from open necrosectomy in a tertiary referral Hepatobiliary unit over the last decade.

METHODS

During the period January 1, 2000 to July 31, 2008, 1535 patients were admitted with a final discharge code of acute pancreatitis. Twenty-eight (1.8%) of all admissions underwent open surgical necrosectomy. Twenty-four (86%) were tertiary referral patients.

RESULTS

The median APACHE II score on admission was 10.5 (5-26). Median logistic organ dysfunction score on admission was 3 (0-10). Median LODS score after surgery was 2 (0-8). Twenty patients (71%) underwent radiologically guided drainage of collections before surgery. Thirty-day mortality occurred in 2 (7%), 4 further deaths occurred in patients after discharge from intensive care resulting in a total of 6 (22%) episode-related deaths.

CONCLUSIONS

Modern open necrosectomy can be performed without the procedure-related deterioration in organ dysfunction associated with major debridement. Multidisciplinary care with an emphasis on aggressive radiologic intervention before and after surgery results in acceptable outcomes in this cohort of critically ill patients. Newer laparoscopic techniques must demonstrate similar outcomes in the setting of stage-matched severity before wider acceptance.

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis

BACKGROUND

Pancreatic necrosis may complicate severe acute pancreatitis, and is detectable by computed tomography (CT). If it becomes infected mortality increases, but the use of prophylactic antibiotics raises concerns about antibiotic resistance and fungal infection.

OBJECTIVES

To determine the efficacy and safety of prophylactic antibiotics in acute pancreatitis complicated by CT proven pancreatic necrosis.

SEARCH STRATEGY

Searches were updated in November 2008, in The Cochrane Library (Issue 2, 2008), MEDLINE, EMBASE, and CINAHL. Conference proceedings and references from found articles were also searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotics versus placebo in acute pancreatitis with CT proven necrosis.

DATA COLLECTION AND ANALYSIS

Primary outcomes were mortality and pancreatic infection rates. Secondary end-points included non pancreatic infection, all sites infection, operative rates, fungal infections, and antibiotic resistance. Subgroup analyses were performed for antibiotic regimen (beta-lactam, quinolone, and imipenem).

MAIN RESULTS

Seven evaluable studies randomised 404 patients. There was no statistically significant effect on reduction of mortality with therapy: 8.4% versus controls 14.4%, and infected pancreatic necrosis rates: 19.7% versus controls 24.4%. Non-pancreatic infection rates and the incidence of overall infections were not significantly reduced with antibiotics: 23.7% versus 36%; 37.5% versus 51.9% respectively. Operative treatment and fungal infections were not significantly different. Insufficient data were provided concerning antibiotic resistance.With beta-lactam antibiotic prophylaxis there was less mortality (9.4% treatment, 15% controls), and less infected pancreatic necrosis (16.8% treatment group, 24.2% controls) but this was not statistically significant. The incidence of non-pancreatic infections was non-significantly different (21% versus 32.5%), as was the incidence of overall infections (34.4% versus 52.8%), and operative treatment rates. No significant differences were seen with quinolone plus imidazole in any of the end points measured. Imipenem on its own showed no difference in the incidence of mortality, but there was a significant reduction in the rate of pancreatic infection (p=0.02; RR 0.34, 95% CI 0.13 to 0.84).

AUTHORS' CONCLUSIONS

No benefit of antibiotics in preventing infection of pancreatic necrosis or mortality was found, except for when imipenem (a beta-lactam) was considered on its own, where a significantly decrease in pancreatic infection was found. None of the studies included in this review were adequately powered. Further better designed studies are needed if the use of antibiotic prophylaxis is to be recommended.

Effects of gadolinium chloride and glycine on hepatic and pancreatic tissue damage in alcoholic pancreatitis

OBJECTIVE

Systemic complications in alcoholic pancreatitis are supposed to be aggravated by inflammatory liver damage. Resident macrophages including hepatic Kupffer cells play a pivotal role in mediating systemic complications in severe necrotizing pancreatitis (SNP). The aim of this study was to evaluate the effects of Kupffer cell inhibition on the inflammatory liver damage in experimental alcoholic pancreatitis.

METHODS

Rats were fed with either alcohol or control diet for 6 weeks before induction of SNP. Animals were allocated into 4 groups: healthy controls, controls with SNP, SNP with gadolinium chloride or glycine (permanent vs temporary inhibition of hepatic Kupffer cells) prophylaxis. Hepatic microcirculation and morphologic damage of the liver and pancreas were assessed.

RESULTS

Alcohol feeding and SNP increased hepatic and pancreatic injury compared with SNP alone. Gadolinium chloride and glycine improved hepatic microcirculation. In contrast, pancreatic and hepatic morphological damage was reduced by gadolinium chloride but not by glycine.

CONCLUSIONS

Alcohol exposure aggravates hepatic and pancreatic injury in SNP. Gadolinium chloride reduces both microcirculatory and morphological damage, whereas glycine did not improve histological damage.

Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach

OBJECTIVE

Comparison of minimal access retroperitoneal pancreatic necrosectomy (MARPN) versus open necrosectomy in the treatment of infected or nonresolving pancreatic necrosis.

SUMMARY OF BACKGROUND DATA

Infected pancreatic necrosis may lead to progressive organ failure and death. Minimal access techniques have been developed in an attempt to reduce the high mortality of open necrosectomy.

METHODS

This was a retrospective analysis on a prospective data base comprising 189 consecutive patients undergoing MARPN or open necrosectomy (August 1997 to September 2008). Outcome measures included total and postoperative ICU and hospital stays, organ dysfunction, complications and mortality using an intention to treat analysis.

RESULTS

Overall 137 patients underwent MARPN versus open necrosectomy in 52. Median (range) age of the patients was 57.5 (18-85) years; 118 (62%) were male. A total of 131 (69%) patients were tertiary referrals, with a median time to transfer from index hospital of 19 (2-76) days. Etiology was gallstones or alcohol in 129 cases (68%); 98 of 168 (58%) patients had a positive culture at the first procedure. Of the 137 patients, 34 (31%) had postoperative organ failure in the MARPN group, and 39 of 52 (56%) in the open group (P<0.0001); 59/137 (43%) versus 40/52 (77%), respectively, required postoperative ICU support (P<0.0001). Of the 137 patients 75 (55%) had complications in the MARPN group and 42 of 52 (81%) in the open group (P=0.001). There were 26 (19%) deaths in the MARPN group and 20 (38%) following open procedure (P=0.009). Age (P<0.0001), preoperative multiorgan failure (P<0.0001), and surgical procedure (MARPN, P=0.016) were independent predictors of mortality.

CONCLUSION

This study has shown significant benefits for a minimal access approach including fewer complications and deaths compared with open necrosectomy.

A step-up approach or open necrosectomy for necrotizing pancreatitis

BACKGROUND

Necrotizing pancreatitis with infected necrotic tissue is associated with a high rate of complications and death. Standard treatment is open necrosectomy. The outcome may be improved by a minimally invasive step-up approach.

METHODS

In this multicenter study, we randomly assigned 88 patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue to undergo primary open necrosectomy or a step-up approach to treatment. The step-up approach consisted of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy. The primary end point was a composite of major complications (new-onset multiple-organ failure or multiple systemic complications, perforation of a visceral organ or enterocutaneous fistula, or bleeding) or death.

RESULTS

The primary end point occurred in 31 of 45 patients (69%) assigned to open necrosectomy and in 17 of 43 patients (40%) assigned to the step-up approach (risk ratio with the step-up approach, 0.57; 95% confidence interval, 0.38 to 0.87; P=0.006). Of the patients assigned to the step-up approach, 35% were treated with percutaneous drainage only. New-onset multiple-organ failure occurred less often in patients assigned to the step-up approach than in those assigned to open necrosectomy (12% vs. 40%, P=0.002). The rate of death did not differ significantly between groups (19% vs. 16%, P=0.70). Patients assigned to the step-up approach had a lower rate of incisional hernias (7% vs. 24%, P=0.03) and new-onset diabetes (16% vs. 38%, P=0.02).

CONCLUSIONS

A minimally invasive step-up approach, as compared with open necrosectomy, reduced the rate of the composite end point of major complications or death among patients with necrotizing pancreatitis and infected necrotic tissue. (Current Controlled Trials number, ISRCTN13975868.)

Total enteral nutrition in prevention of pancreatic necrotic infection in severe acute pancreatitis

OBJECTIVE

This study was designed to evaluate the effects of total enteral nutrition and total parenteral nutrition in prevention of pancreatic necrotic infection in severe acute pancreatitis.

METHODS

One hundred seven patients were enrolled in the study between 2003 and 2007. In the first week of hospitalization, they were randomized to feeding by either total parenteral nutrition (54 patients) or total enteral nutrition (53 patients). All patients were concomitantly administered with sufficient prophylactic antibiotics. Computed tomographic scan and C-reactive protein level indicated a similar clinical severity in both groups.

RESULTS

Eighty percent of the patients developed organ failure in the group with total parenteral nutrition, which was higher than that in the group with total enteral nutrition (21%). Eighty percent and 22% (P < 0.05) of the patients in the total parenteral nutrition and total enteral nutrition groups, respectively, underwent surgical intervention. The incidence of pancreatic septic necroses in the group with total enteral nutrition (23%) was lower than that in the group with total parenteral nutrition (72%, P < 0.05). Mortality in the total parenteral nutrition group (43%) was higher than in the total enteral nutrition group (11%, P < 0.05).

CONCLUSION

Total enteral nutrition is better than total parenteral nutrition in the prevention of pancreatic necrotic infection in severe acute pancreatitis.

Surgical management of pancreatic necrosis: towards lesser and later

BACKGROUND/PURPOSE

Our aim was to determine the overall success rate and survival rate with respect to the timing of intervention in the management of pancreatic necrosis. The use of minimally invasive pancreatic necrosectomy was also examined.

METHODS

This was a retrospective study carried out in a tertiary referral hospital. The subjects were all patients who suffered from acute pancreatic necrosis with emergency interventions from January 2001 to December 2007. For outcome measures, special emphasis was placed on the overall success rate and survival rate with respect to the timing of intervention. The success rate of percutaneous pancreatic necrosectomy (PCPN) was examined.

RESULTS

A total of 26 patients with pancreatic necrosis were studied. The overall mortality rate was 26.9% and the rate was significantly higher in those patients who had earlier intervention (before 6 weeks). Eleven patients had PCPN. There were 2 failures due to PCPN in the early phase; 2 had partial success, while the procedure was completely successful to remove all the necrotic tissues in the other 7 patients.

CONCLUSIONS

With a multidisciplinary approach, particularly with sophisticated intensive care, most patients with pancreatic necrosis can survive the initial phase. Open surgery should be limited to simple drainage and laparostomy to relieve the abdominal tension. Active intervention preferably should be delayed until the necrosis has become walled off, when a variety of minimally invasive maneuvers, notably percutaneous necrosectomy, can be offered to remove the debris. The surgical management of pancreatic necrosis should change towards a strategy of "lesser and later".

Analysis of clinical course of severe acute biliary and non biliary pancreatitis: a comparative study

Az akut pancreatitis viszonylag gyakran előforduló betegség. Évenként 5 és 80 közötti új megbetegedés esik 100 000 lakosra, és ez a szám az utóbbi években növekedést mutat a különböző tanulmányok szerint. A két fő etiológiai faktor az alkohol és az epekövesség. Az alkoholos eredetű hasnyálmirigy-gyulladás a férfiak körében, a biliaris pancreatitis a nők körében gyakoribb. Célkitűzés: a szerzők súlyos akut pancreatitis miatt kezelt betegek adatait elemezik, arra keresve a választ, hogy milyen eltérő sajátságokkal rendelkezik a biliaris és a más etiológiájú pancreatitis. Betegek és módszer: a szerzők 139, súlyos akut pancreatitisben szenvedő beteget kezeltek, akiket etiológiai szempontból két csoportra osztottak: az epeköves (A csoport) és a nem epeköves (B csoport) talajon kialakult súlyos hasnyálmirigy-gyulladásban szenvedők csoportjára. Összehasonlították a két csoport nem és kor szerinti sajátosságait, a mortalitási és a morbiditási adatokat, a műtétek és az ápolási napok számát. A statisztikai analízishez a χ 2 -tesztet alkalmazták. Eredmények: a szövődmények az epés (A) csoportban súlyosabbak voltak, mint a nem epés (B) csoportban. A halálozás az A csoportban 17,8%-nak, a B csoportban 13,8%-nak bizonyult, míg az átlagos 15,1% volt. A mortalitás a nők körében az A csoportban szignifikánsan magasabb volt. Következtetések: a súlyos epés akut pancreatitisben szenvedő nőbetegek esetében súlyosabb lefolyással, magasabb halálozási aránnyal kell számolnunk. A szerzők az idős, egyéb betegségekkel terhelt epeköves nőknél még a szövődmények jelentkezése előtt elektív cholecystectomiát javasolnak.

Characteristics and outcomes of patients undergoing debridement of pancreatic necrosis

BACKGROUND

Pancreatic necrosis is associated with high morbidity and mortality. The Atlanta Classification underwent proposed revisions in 2007 to better categorize acute pancreatitis.

METHODS

From 1999 to 2008, patients with pancreatic necrosis treated with surgical debridement were analyzed. Computed tomography (CT) images were independently reviewed to classify of pancreatic collections according to the revised Atlanta classification.

RESULTS

Seventy-three patients were categorized as infected extrapancreatic necrosis (40%), sterile extrapancreatic necrosis (29%), infected pancreatic necrosis (15%), sterile pancreatic necrosis (11%), or post-necrotic collection (5%). Mortality was 14%, and morbidity was 55%. Debridement with external drainage or open packing was associated with higher mortality than cystgastrostomy (p = 0.03). Atlanta Classification was not associated with operative procedure or mortality. Degree of chronic disease, demonstrated by albumin level, and infection were associated with longer stay (p < 0.05).

CONCLUSION

Type of necrosis by the revised Atlanta Classification was not associated with outcomes or type of operation. Debridement by cystgastrostomy was associated with lower mortality rates than external drainage or open packing. Length of stay was increased in patients with evidence of chronic disease, infection, and postoperative complications. Necrotizing pancreatitis continues to be associated with significant morbidity and mortality and should undergo aggressive treatment at tertiary care centers.

'Pipe-organ'-like retroperitoneal drainage in severe necrotizing pancreatitis

Infected pancreatic necrosis is a severe complication of acute pancreatitis; this complication is the major cause of death. We used the 'pipe-organ' -like retroperitoneal drainage, which is usually used in the management of open pelvic fracture, successfully in a patient with severe infected pancreatic necrosis. This procedure can avoid gastrointestinal fistula and local bleeding without necessitating surgery.