High volume lesser sac lavage in acute necrotizing pancreatitis

Management of severe acute pancreatitis

The risks, measurements of severity, and management of severe acute pancreatitis and its complications have evolved rapidly over the past decade. Evidence suggests that initial goal directed therapy, nutritional support, and vigilance for pancreatic complications are best practice. Patients can develop pancreatic fluid collections including acute pancreatic fluid collections, pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Several randomized controlled trials and cohort studies have recently highlighted the advantage of managing these conditions with a progressive approach, with initial draining for infection followed by less invasive techniques. Surgery is no longer an early intervention and may not be needed. Instead, interventional radiologic and endoscopic methods seem to be safer with at least as good survival outcomes. Newly developed evidence based quality indicators are available to assess and improve performance. Development and clinical testing of drugs to target the mechanisms of disease are necessary for further advancements.

Interventions for necrotising pancreatitis

BACKGROUND

Acute necrotising pancreatitis carries significant mortality, morbidity, and resource use. There is considerable uncertainty as to how people with necrotising pancreatitis should be treated.

OBJECTIVES

To assess the benefits and harms of different interventions in people with acute necrotising pancreatitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 4), MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers to April 2015 to identify randomised controlled trials (RCT). We also searched the references of included trials to identify further trials.

SELECTION CRITERIA

We considered only RCTs performed in people with necrotising pancreatitis, irrespective of aetiology, presence of infection, language, blinding, or publication status for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and extracted data. We calculated the odds ratio (OR) and mean difference with 95% confidence intervals (CI) using Review Manager 5 based on an available-case analysis using fixed-effect and random-effects models. We planned a network meta-analysis using Bayesian methods, but due to sparse data and uncertainty about the transitivity assumption, performed only indirect comparisons and used Frequentist methods.

MAIN RESULTS

We included eight RCTs with 311 participants in this review. After exclusion of five participants, we included 306 participants in one or more outcomes. Five trials (240 participants) investigated the three main treatments: open necrosectomy (121 participants), minimally invasive step-up approach (80 participants), and peritoneal lavage (39 participants) and were included in the network meta-analysis. Three trials (66 participants) investigated the variations in the main treatments: early open necrosectomy (25 participants), delayed open necrosectomy (11 participants), video-assisted minimally invasive step-up approach (12 participants), endoscopic minimally invasive step-up approach (10 participants), minimally invasive step-up approach (planned surgery) (four participants), and minimally invasive step-up approach (continued percutaneous drainage) (four participants). The trials included infected or sterile necrotising pancreatitis of varied aetiology.All the trials were at unclear or high risk of bias and the overall quality of evidence was low or very low for all the outcomes. Overall, short-term mortality was 30% and serious adverse events rate was 139 serious adverse events per 100 participants. The differences in short-term mortality and proportion of people with serious adverse events were imprecise in all the comparisons. The number of serious adverse events and adverse events were fewer in the minimally invasive step-up approach compared to open necrosectomy (serious adverse events: rate ratio 0.41, 95% CI 0.25 to 0.68; 88 participants; 1 study; adverse events: rate ratio 0.41, 95% CI 0.25 to 0.68; 88 participants; 1 study). The proportion of people with organ failure and the mean costs were lower in the minimally invasive step-up approach compared to open necrosectomy (organ failure: OR 0.20, 95% CI 0.07 to 0.60; 88 participants; 1 study; mean difference in costs: USD -11,922; P value < 0.05; 88 participants; 1 studies). There were more adverse events with video-assisted minimally invasive step-up approach group compared to endoscopic-assisted minimally invasive step-up approach group (rate ratio 11.70, 95% CI 1.52 to 89.87; 22 participants; 1 study), but the number of interventions per participant was less with video-assisted minimally invasive step-up approach group compared to endoscopic minimally invasive step-up approach group (difference in medians: 2 procedures; P value < 0.05; 20 participants; 1 study). The differences in any of the other comparisons for number of serious adverse events, proportion of people with organ failure, number of adverse events, length of hospital stay, and intensive therapy unit stay were either imprecise or were not consistent. None of the trials reported long-term mortality, infected pancreatic necrosis (trials that included participants with sterile necrosis), health-related quality of life at any time frame, proportion of people with adverse events, requirement for additional invasive intervention, time to return to normal activity, and time to return to work.

AUTHORS' CONCLUSIONS

Low to very low quality evidence suggested that the minimally invasive step-up approach resulted in fewer adverse events, serious adverse events, less organ failure, and lower costs compared to open necrosectomy. Very low quality evidence suggested that the endoscopic minimally invasive step-up approach resulted in fewer adverse events than the video-assisted minimally invasive step-up approach but increased the number of procedures required for treatment. There is currently no evidence to suggest that early open necrosectomy is superior or inferior to peritoneal lavage or delayed open necrosectomy. However, the CIs were wide and significant benefits or harms of different treatments cannot be ruled out. The TENSION trial currently underway in Netherlands is assessing the optimal way to perform the minimally invasive step-up approach (endoscopic drainage followed by endoscopic necrosectomy if necessary versus percutaneous drainage followed by video-assisted necrosectomy if necessary) and is assessing important clinical outcomes of interest for this review. Implications for further research on this topic will be determined after the results of this RCT are available.

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015

BACKGROUND

Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines.

METHODS

A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines.

RESULTS

Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles.

CONCLUSIONS

The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.

The role of open necrosectomy in the current management of acute necrotizing pancreatitis: a review article

The optimal management of necrotizing pancreatitis continues to evolve. Currently, conservative intensive care treatment represents the primary therapy of acute severe necrotizing pancreatitis, aiming at prevention of organ failure. Following this mode of treatment most patients with sterile necroses can be managed successfully. Surgery might be considered as an option in the late phase of the disease for patients with proven infected pancreatic necroses and organ failure. For these patients surgical debridement is still considered the treatment of choice. However, even for this subgroup of patients, the concept of operative strategy has been recently challenged. Nowadays, it is generally accepted that necrotizing pancreatitis with proven infected necroses as well as septic complications directly caused by pancreatic infection are strong indications for surgical management. However, the question of the most appropriate surgical technique for the treatment of pancreatic necroses remains unsettled. At the same time, recent advances in radiological imaging, new developments in interventional radiology, and other minimal access interventions have revolutionised the management of necrotizing pancreatitis. In light of these controversies, the present paper will focus on the current role of surgery in terms of open necrosectomy in the management of severe acute necrotizing pancreatitis.

Clinical pancreatology I: Pancreatic medical history

The present article and subsequent reviews will not be to report all what has been published, but rather to give an introduction samples that hopefully make the reader eager to read the whole article or articles with "a taste of clinical pancreatology in 2010". The main sources of literatures were PubMed, and the additional Journals such as Pancreas, Pancreatology and Journal of the Pancreas were also scrutinized. Only some full articles in almost all languages were included in the review, other articles, however, that were too superficial or too poor in other ways, were omitted, and the publications of non-human study were excluded.

Treatment of acute pancreatitis: an attempted historical review

This attempt at a historical review of the treatment of acute pancreatitis summarizes the findings of studies carried out in decades long past and shows their impact on the therapy of this disease today. It identifies in retrospect the correct avenues of research and the blind alleys, and describes the ebb and flow of interest in various forms of management. Acquaintance with the work of previous investigators may prevent the unnecessary rediscovery of old principles of treatment. Not all of the studies discussed can be found with search engines: they come from the author's personal library, collected over his 40 years as an active pancreatologist, and from the knowledge of the early literature bequeathed to him by his teachers and mentors.

In situ high-volume modified continuous closed and/or open lavage for infected necrotizing pancreatitis

OBJECTIVES

To evaluate the clinical significance of high-volume modified continuous closed and/or open lavage for the treatment of infected necrotizing pancreatitis.

METHODS

From August 1997 to December 2006, 53 patients with infected necrotizing pancreatitis who underwent in situ high-volume (>20 L/d) continuous closed lavage using a single-lumen rubber catheter and/or open lavage were retrospectively studied in our hospital, and the advantages of this new technique were analyzed.

RESULTS

Modified continuous closed lavage was the initial treatment for all patients; in 6 patients with secondary retroperitoneal sepsis or abscess, continuous open lavage was performed. Impaired tube patency and lavage fluid retention did not occur in any of these patients. The overall mortality was 17.0% (9/53). Twelve patients underwent early surgery, and 5 (41.7%) died; 41 patients underwent delayed surgery, and 4 (9.8%) died. Significant local complications occurred in 14 patients (26.4%); the incidence of bleeding, abscess, and fistula was 13.2% (7/53), 9.4% (5/53), and 9.4% (5/53), respectively.

CONCLUSIONS

Our technique of in situ high-volume modified continuous closed and/or open lavage has produced a better control of infected necrotizing pancreatitis.

Closed lesser sac lavage in the management of pancreatic necrosis

BACKGROUND AND AIM

Surgery for pancreatic necrosis complicating acute severe pancreatitis carries a high risk of morbidity and mortality. We evaluated the efficacy of necrosectomy and closed lesser sac lavage as a method of management of pancreatic necrosis.

METHODS

Fifty-eight patients with pancreatic necrosis who underwent pancreatic necrosectomy consecutively in a tertiary care referral center were retrospectively analyzed. The technique of necrosectomy and postoperative lavage is described in detail. Details regarding the patient profile, disease severity, surgical details, postoperative morbidity, repeat interventions and the mortality are presented.

RESULTS

Of the 58 patients, irrigation was able to be started in 48. Lavage was able to be continued until disease resolution or death in all but 10 patients. Post-operative locoregional complications were residual abscesses in 10, bleeding in eight, enteric fistulae in 12 and pancreatic fistulae in nine. Six patients needed postoperative percutaneous procedures, while 16 patients needed repeat surgery. Seventeen patients died (29%), all of whom had multiple organ failure involving more than two organs, while 11 developed sepsis.

CONCLUSION

Pancreatic necrosectomy and postoperative closed lesser sac lavage is an effective method of managing these patients, with acceptable morbidity, re-operation rates and mortality.

Outcome of open necrosectomy in acute pancreatitis

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

Management of severe acute pancreatitis

BACKGROUND

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

METHODS

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

RESULTS AND CONCLUSION

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

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

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

A meta-analysis of peritoneal lavage for acute pancreatitis

BACKGROUND AND AIM

It has been postulated that continuous irrigation of the peritoneal cavity with crystalloid solutions in patients with acute pancreatitis can improve mortality and morbidity. The aim of the study is to perform a meta-analysis of available randomized prospective clinical trials, to evaluate whether lavage influences mortality and morbidity in patients with acute pancreatitis.

METHODS

We performed a computer search of Medline for all available literature on the use of lavage in patients with acute pancreatitis. A meta-analysis was conducted on eight randomized, prospective, clinical trials (a total of 333 patients) evaluating continuous peritoneal lavage in patients with acute pancreatitis. The end-points were mortality and morbidity (i.e. pancreatic necrosis, peripancreatic fluid collections, intra-abdominal abscess formation, septicemia, organ system failure).

RESULTS

Continuous lavage did not improve either mortality (weighted mean difference 1.6%, 95% CI -6.7% to 9.9%, not significant (n.s.)) or morbidity (weighted mean difference 6.2%, 95% CI -3.2% to 15.6%, n.s.) when compared with control patients.

CONCLUSIONS

The use of continuous peritoneal lavage in patients with acute pancreatitis has not been found to be associated with any significant improvement in mortality or morbidity.

Surgical management of necrotizing pancreatitis

In necrotizing pancreatitis, surgical treatment is indicated in patients with infected necrosis. Conservative management should be favored if necrosis remains sterile and the patient responds to intensive care therapy. Different surgical techniques have been established during the past years, including conventional drainage, open and semiopen drainage, and closed management with postoperative continuous lavage of the lesser sac. For experienced physicians, these techniques provide comparable results, and none has been proved to be superior to the others.

Diagnosis, objective assessment of severity, and management of acute pancreatitis. Santorini consensus conference

BACKGROUND

The diagnosis, early assessment, and management of severe acute pancreatitis remain difficult clinical problems. This article presents the consensus obtained at a meeting convened to consider the evidence in these areas. The aim of the article is to provide outcome statements to guide clinical practice, with an assessment of the supporting evidence for each statement.

METHOD

Working groups considered the published evidence in the areas of diagnosis, assessment of severity, nonoperative treatment, and surgical treatment of severe acute pancreatitis. Outcome statements were defined to summarize the conclusions on each point considered. The findings were discussed and agreed on by all participants. A careful assessment was made of the strength of the available evidence (proven, probable, possible, unproven, or inappropriate).

FINDINGS AND CONCLUSIONS

There is reliable evidence to support much current practice. Clear guidance can be given in most areas examined, and several areas were identified where further investigation would be helpful. Diagnosis using plasma concentrations of pancreatic enzymes is reliable. Rapid advances are taking place in the assessment of severity. Several new therapeutic strategies show real promise for the reduction of morbidity and mortality rates. Surgical debridement is required for infected pancreatic necrosis, but is less often necessary for sterile necrosis.

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

AIM OF THE STUDY

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Difference in microbes contaminating pancreatic necrosis in biliary and alcoholic pancreatitis

CONCLUSION

There are differences in the microbiology of infected pancreatic necrosis in alcoholic and biliary pancreatitis. One possible explanation may be different routes of contamination.

BACKGROUND

Infection is a severe complication in acute pancreatitis. Bacteria are found in 40-70% of all patients suffering from necrotizing pancreatitis. We investigated whether there were any differences in microbes isolated from pancreatic necrosis in biliary and alcoholic pancreatitis.

METHODS

Microbiological tests were conducted on necrosis taken at the operation for pancreatitis with the etiology of (group A) alcoholic pancreatitis (n = 47) and (group B) biliary pancreatitis (n = 23). Patients with simultaneous cholecystitis were excluded. The time from the first symptoms to the operation or the extent of necrosis did not differ between the groups.

RESULTS

Microbes were isolated more often in the cultures from group B than group A (17/23 = 74% vs 15/47 = 32%, p = 0.001). The most common were Gram-positive bacteria in group A and Gram-negative bacteria in group B. From the first week, from the onset of symptoms to the operation. Gram-negative bacteria were isolated significantly more often in the cultures from group B patients than from group A patients (8/10 = 80% vs 1/5 = 20%, p = 0.04). In multivariate analysis, we found that biliary pancreatitis was an independent risk factor (adds ratio 5.5, 95% confidence interval [CI] 0.59-52.10) of contamination of necrosis with Gram-negative bacteria.

Management of necrotizing pancreatitis by repeated operative necrosectomy using a zipper technique

METHODS

From 1983 to 1995, 72 patients with necrotizing pancreatitis were treated with a general approach involving planned reoperative necrosectomies and interval abdominal wound closure using a zipper.

RESULTS

Hospital mortality was 25%. Multiple organ failure without sepsis caused early mortality in 3 of 4 patients and sepsis caused late mortality in 11 of the remaining 14. The mean number of reoperative necrosectomies/debridements was 2 (0 to 7). Fistulae developed in 25 patients (35%); 64% were treated conservatively. Recurrent intraabdominal abscesses developed in 9 patients (13%) but were drained percutaneously in 5. Hemorrhage required intervention in 13 patients (18%). Prognostic factors included APACHE-II score on admission < 13 (P = 0.005), absence of postoperative hemorrhage (P = 0.01), and peripancreatic tissue necrosis alone (P < 0.05).

CONCLUSIONS

The zipper approach effectively maximizes the necrosectomy and decreases the incidence of recurrent intraabdominal infection requiring reoperation. APACHE-II score > or = 13, extensive parenchymal necrosis, and postoperative hemorrhage signify worse outcome.

Drainage tube endoscopy: a contribution to the management of severe acute pancreatitis?

Peritoneal lavage is one of the interventional approaches that have gained some attention in the early, toxaemic phase of acute pancreatitis. Additionally some kind of drainage is necessary for suppurative collections that characterize the late phase of the disease. In both the above situations tube plugging is a common problem and it is usually associated with a relapse of the patient's septic state and newly formed collection(s) on abdominal CT. Two cases are presented, in early and in late phases respectively, in which drainage tube adoscopy (DTE) re-established tube patency and ensured drainage. DTE may represent an alternative to surgery or to CT-guided paracentesis and evacuation of newly formed intra-abdominal collections secondary to tube obstruction.

Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains

We reviewed our recent experience with management of 23 consecutive patients with acute necrotizing pancreatitis. All patients had documented necrotizing pancreatitis with parenchymal or peripancreatic necrosis. Our method of treatment has evolved from our previous approach of controlled open lesser sac drainage (marsupialization) to staged necrosectomy/debridement with delayed primary closure over drains. With this latter approach, hospital mortality was 4 of 23 patients (17 per cent), but significant morbidity still occurred in 12 of 23 patients (52 per cent). However, recurrent intra-abdominal abscess before discharge occurred in only one patient. We believe that this operative approach toward the severely ill patient with acute necrotizing pancreatitis who requires operative intervention will minimize the occurrence of intra-abdominal sepsis.

Surgical strategies in the treatment of pancreatic necrosis and infection

Controversy still surrounds the management of necrotic and septic complications of acute pancreatitis. A review of the literature of the past decade dealing with the surgical treatment of pancreatic necrosis, pancreatic abscess and infected pancreatic necrosis has been undertaken. Three main patterns of management could be identified: (1) 'conventional treatment', consisting of pancreatic resection or necrosectomy with drainage; (2) 'local lavage', consisting of necrosectomy followed by regional lavage; and (3) 'open management', with resection or necrosectomy followed by planned multiple re-explorations. From this review it appears that local lavage and open management offer better survival prospects than conventional treatment. Open abdomen techniques, however, are associated with an increased risk of complications, such as colonic necrosis, intestinal fistula, and intra-abdominal bleeding. Excellent results can be achieved in specialized centres with any of the three methods, provided adequate debridement and prompt reoperations are undertaken if the septic state persists.

A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis

Pancreatic necrosis is now recognized as a principal determinant of survival in acute pancreatitis. However, it is currently unknown how frequently pancreatic necrosis develops in acute pancreatitis, how often pancreatic necrosis becomes secondarily infected, and whether sterile pancreatic necrosis represents an indication for surgery or can be treated by conservative means. In 194 patients with unequivocal acute pancreatitis, pancreatic necrosis developed in 38 (20%), as documented by dynamic pancreatography, and was confirmed by histologic diagnosis at surgery in 28. All patients were prospectively treated by medical means. Patients with pancreatic necrosis who remained persistently febrile underwent fine needle aspiration for bacterial culture. Infected pancreatic necrosis was demonstrated in 27 of the 38 patients (71%) with pancreatic necrosis and was treated by open drainage, yielding a mortality rate of 15%. All 11 patients with demonstrated sterile pancreatic necrosis, including 6 with pulmonary and renal insufficiency, were successfully treated without surgery. Pancreatic necrosis occurs in approximately 20% of patients with acute pancreatitis and is necessary for the development of secondary pancreatic infection. However, pancreatic necrosis by itself, even when accompanied by organ failure, is not an absolute indication for surgery. A trial of medical treatment for all patients with sterile pancreatic necrosis is in order.

Long peritoneal lavage decreases pancreatic sepsis in acute pancreatitis

Late infection of devitalized pancreatic and peripancreatic tissue has become the major cause of morbidity in severe acute pancreatitis. Previous experience found that peritoneal lavage for periods of 48 to 96 hours may reduce early systemic complications but did not decrease late pancreatic sepsis. A fortunate observation led to the present study of the influence of a longer period of lavage on late sepsis. Twenty-nine patients receiving primary nonoperative treatment for severe acute pancreatitis (three or more positive prognostic signs) were randomly assigned to short peritoneal lavage (SPL) for 2 days (15 patients) or to long peritoneal lavage (LPL) for 7 days (14 patients). Positive prognostic signs averaged 5 in both groups but the frequency of five or more signs was higher in LPL (71%) than in SPL (47%). Eleven patients in each group had early computed tomographic (CT) scans. Peripancreatic fluid collections were shown more commonly in LPL (82%) than in SPL (54%) patients. Longer lavage dramatically reduced the frequency of both pancreatic sepsis (22% LPL versus 40% SPL) and death from sepsis (0% LPL versus 20% SPL). Among patients with fluid collections on early CT scan, LPL led to a more marked reduction in both pancreatic sepsis (33% LPL versus 83% SPL) and death from sepsis (0% LPL versus 33% SPL). The differences were even more striking among 17 patients with five or more positive prognostic signs. In this group the incidence of pancreatic sepsis was 30% LPL versus 57% SPL and of death from sepsis 0% (LPL) versus 43% (SPL) (p = 0.05). In these patients, overall mortality was also reduced (20% LPL versus 43% SPL). When 20 patients treated by LPL were compared with 91 other patients with three or more positive prognostic signs who were treated without lavage or by lavage for periods of 2 to 4 days, the frequency of death from pancreatic sepsis was reduced from 13% to 5%. In those with five or more signs, the incidence of sepsis was reduced from 40% to 27% (p = 0.03) and of death for sepsis from 30% to 7% (p = 0.08). These findings indicate that lavage of the peritoneal cavity for 7 days may significantly reduce both the frequency and mortality rate of pancreatic sepsis in severe acute pancreatitis.

Surgical management of acute pancreatitis

This review examines the lack of improvement in terms of mortality and outcome in patients with acute pancreatitis. Energetic fluid replacement is the only treatment of proven value. There is a strong case for identification of patients with severe disease who may benefit from early operative intervention. Eradication of gallstones may prevent further attacks in patients with gallstone pancreatitis. The benefits of pancreatic resection and necrosectomy still require full evaluation.