Necrotizing pancreatitis: Indications for surgery and surgical techniques

Prevalence and predictors of severity as defined by atlanta criteria among patients presenting with acute pancreatitis

INTRODUCTION

Effective triage of patients with acute pancreatitis is dependent on the ability to accurately predict a severe course. Predictors (e.g., APACHE II score of >8) have been tested against wide-ranging definitions of severity (prevalence, 15%-40%). To ensure uniformity in defining a severe course of acute pancreatitis, the Atlanta symposium of 1992 adopted all-encompassing criteria (local complications, systemic complications, need for surgery, or death).

AIMS

To assess the prevalence of each Atlanta criteria for severe acute pancreatitis and to determine the sensitivity, specificity, and positive and negative predictive values of the APACHE II score as a predictor of these criteria for severe acute pancreatitis.

METHODOLOGY

We reviewed records of patients admitted to the University of Cincinnati Medical Center (Cincinnati, OH, U.S.A.) between 1994 and 1998 with acute pancreatitis. Exclusion criteria included referral from an outside hospital, immunocompromised state, and chronic pancreatitis.

RESULTS

Seventy-four consecutive patients met our inclusion criteria. Ten patients (13.5%) had a severe course. Seven patients developed only local complications. Three patients had systemic complications. Pancreatic surgical intervention was required in four patients. No deaths occurred. An APACHE II score of >8 exhibited 50% sensitivity and 69% specificity (positive predictive value, 20%; negative predictive value, 89%). All patients with systemic complications and two of seven patients with only local complications had an APACHE II score of >8.

CONCLUSIONS

The prevalence of severity among our nonreferred patients with acute pancreatitis was less than previously reported. The APACHE II scoring system exhibited reasonable sensitivity in predicting systemic complications and/or the need for surgery, with a low positive predictive value. This most certainly is a function of the low pretest probability of severe pancreatitis. Future studies attempting to identify predictive systems that triage patients in a more cost-effective manner should restrict their analysis to Atlanta criteria other than local complications.

Evidence for a central role for selective mesenteric angiography in the management of the major vascular complications of pancreatitis

BACKGROUND

Although mesenteric angiography and embolization are established radiologic procedures, the evidence-base to aid decision making regarding selection of these procedures in the emergent situation in patients with hemorrhagic complications of pancreatitis is limited.

METHODS

A retrospective analysis of 19 patients with hemorrhagic complications of pancreatic inflammatory disease (acute pancreatitis, chronic pancreatitis, and pseudocyst) referred over a 4-year period and identified at the point of mesenteric angiography in order to determine the influence of interventional radiologic maneuvers on outcome.

RESULTS

Mesenteric angiography localized bleeding in 15 (79%), with 11 (58%) embolizations undertaken. There was one (9%) procedure-related complication and 3 (27%) rebleeds. Of 11 patients undergoing embolization, 8 (73%) required no further intervention for bleeding and 8 (73%) survived.

CONCLUSIONS

Mesenteric angiography is valuable in localizing bleeding in patients with major vascular complications of pancreatic inflammatory disease. Angiographic embolization can achieve definitive hemostasis and stabilize a critically ill patient to permit disease reappraisal.

Complicated Acute Pancreatitis

The treatment of severe, complicated pancreatitis requires: Rapid assessment and recognition of severity, determined by using APACHE or equivalent scoring systems. Aggressive resuscitation with crystalloid and colloid solutions using central venous monitoring for guidance, and to help identify and treat early organ failure. Nutritional support including total parenteral feeding, which can assist in maintaining nutrition during the prolonged period that may ensue. Nasojejunal feedings, bypassing the duodenum, supply nutrition and may decrease infectious complications. Judicious use of imaging studies, mainly dynamic-bolus contrast computed tomography (CT) of the abdomen. These studies will identify necrosis and other local complications of pancreatitis that are treatable by endoscopic, radiological or surgical means. Antibiotics, whose role has evolved to that of prophylaxis to prevent infection of necrotizing pancreatitis. Other medications such as octreotide have a limited role in the management of certain specific complications such as fistulas and post-pancreatic surgery. A multidisciplinary approach, including the use of endoscopic techniques and surgery to treat complicated pancreatitis. This approach provides optimal care of this challenging group of patients.