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Werge M, Novovic S, Schmidt PN, Gluud LL. Infection increases mortality in necrotizing pancreatitis: A systematic review and meta-analysis. Pancreatology 2016; 16:698-707. [PMID: 27449605 DOI: 10.1016/j.pan.2016.07.004] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 06/07/2016] [Accepted: 07/06/2016] [Indexed: 02/09/2023]
Abstract
OBJECTIVES To assess the influence of infection on mortality in necrotizing pancreatitis. METHODS Eligible prospective and retrospective studies were identified through manual and electronic searches (August 2015). The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). Meta-analyses were performed with subgroup, sensitivity, and meta-regression analyses to evaluate sources of heterogeneity. RESULTS We included 71 studies (n = 6970 patients). Thirty-seven (52%) studies used a prospective design and 25 scored ≥5 points on the NOS suggesting a low risk of bias. Forty studies were descriptive and 31 studies evaluated invasive interventions. In total, 801 of 2842 patients (28%) with infected necroses and 537 of 4128 patients (13%) with sterile necroses died with an odds ratio [OR] of 2.57 (95% confidence interval [CI], 2.00-3.31) based on all studies and 2.02 (95%CI, 1.61-2.53) in the studies with the lowest bias risk. The OR for prospective studies was 2.96 (95%CI, 2.51-3.50). In sensitivity analyses excluding studies evaluating invasive interventions, the OR was 3.30 (95%CI, 2.81-3.88). Patients with infected necrosis and organ failure had a mortality of 35.2% while concomitant sterile necrosis and organ failure was associated with a mortality of 19.8%. If the patients had infected necrosis without organ failure the mortality was 1.4%. CONCLUSIONS Patients with necrotizing pancreatitis are more than twice as likely to die if the necrosis becomes infected. Both organ failure and infected necrosis increase mortality in necrotizing pancreatitis.
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Affiliation(s)
- Mikkel Werge
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark
| | - Srdan Novovic
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark
| | - Palle N Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark
| | - Lise L Gluud
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark.
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The role of open necrosectomy in the current management of acute necrotizing pancreatitis: a review article. ISRN SURGERY 2013; 2013:579435. [PMID: 23431472 PMCID: PMC3569915 DOI: 10.1155/2013/579435] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 01/07/2013] [Indexed: 12/12/2022]
Abstract
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.
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Kingham TP, Shamamian P. Management and Spectrum of Complications in Patients Undergoing Surgical Debridement for Pancreatic Necrosis. Am Surg 2008. [DOI: 10.1177/000313480807401102] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Patients who undergo pancreatic necrosectomy frequently develop complications and often have high mortality rates. These patients are best cared for at specialized centers to minimize morbidity, manage complex complications, and reduce mortality. We present a review of our experience and describe the spectrum of complications encountered in managing of these difficult patients. A registry of patients undergoing pancreatic necrosectomy during a 7-year period was analyzed for preoperative clinical scoring systems (Acute Physiology and Chronic Health Evaluation [APACHE] II and APACHE III scores), patient characteristics related to necrosectomy, and morbidity and mortality. Twenty-nine patients underwent necrosectomy. Indications for surgery were consistent with those previously described. There were 27 complications in 22 patients. Sixteen complications were early (less than 3 weeks after surgery) and 14 were late. The mortality rate was 14 per cent. All deaths were in patients transferred from outside institutions, some after extended time periods. Temporary percutaneous catheter drainage of abscesses before transfer and definitive surgery appeared to reduce mortality in transferred patients. There was a statistically significant correlation between mean maximal preoperative APACHE III score, but not APACHE II score, and the number of postoperative intensive care unit days (rho = 0.52, P = 0.004). We describe our experience managing patients with infected pancreatic necrosis that required operative necrosectomy. We found that more severely ill patients (higher APACHE III scores) had longer intensive care unit stays, but the initial severity of their illness did not increase mortality. If patients with infected pancreatic necrosis are referred to specialized centers, preoperative pre-transfer percutaneous drainage may serve to temporarily control sepsis.
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Affiliation(s)
- T. Peter Kingham
- Department of Surgery, New York University School of Medicine, New York, New York; and the
| | - Peter Shamamian
- Department of Surgery, New York University School of Medicine, New York, New York; and the
- Veterans Administration, New York Harbor Healthcare System, New York, New York
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Mofidi R, Lee AC, Madhavan KK, Garden OJ, Parks RW. Prognostic factors in patients undergoing surgery for severe necrotizing pancreatitis. World J Surg 2007; 31:2002-7. [PMID: 17687599 DOI: 10.1007/s00268-007-9164-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatic necrosectomy remains an important treatment modality for the management of infected pancreatic necrosis but is associated with significant mortality. The aim of this study was to identify factors associated with mortality following pancreatic necrosectomy. Patients who underwent pancreatic necrosectomy from January 1995 to December 2004 were reviewed. The association between admission, preoperative and postoperative variables, and mortality was assessed using logistic regression analysis. A total of 1248 patients presented with acute pancreatitis, of whom 94 (7.5%) underwent pancreatic necrosectomy (51 men, 43 women). The preoperative median Acute Physiology, Age, and Chronic Health Evaluation (APACHE II) score was 9 (range 2-19). The median cumulative organ dysfunction score was 2 (0-9) preoperatively and 4 (1-11) postoperatively. In all, 23 patients (24.5%) died. Those who died were older than the survivors; the ages (median and range) were 69 years (40-80 years) versus 52 years (19-79 years) (p < 0.05). They also had higher admission APACHE II scores (median and range): 14 (12-19) versus 9 (2-22) (p < 0.001). There were significant associations between preoperative (p < 0.01) and postoperative (p < 0.01) Marshall scores and mortality following pancreatic necrosectomy. The presence of the systemic inflammatory response syndrome (SIRS) during the first 48 hours (p < 0.01) and the time between presentation and necrosectomy (p < 0.01) were independent predictors of survival. Pancreatic necrosectomy is associated with higher mortality in patients with increased APACHE II scores, early persistent SIRS, and unresolved multiorgan dysfunction. Necrosectomy is associated with poorer outcome when performed within 2 weeks of presentation.
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Affiliation(s)
- R Mofidi
- Department of Clinical and Surgical Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh, UK
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Cinquepalmi L, Boni L, Dionigi G, Rovera F, Diurni M, Benevento A, Dionigi R. Long-term results and quality of life of patients undergoing sequential surgical treatment for severe acute pancreatitis complicated by infected pancreatic necrosis. Surg Infect (Larchmt) 2006; 7 Suppl 2:S113-6. [PMID: 16895491 DOI: 10.1089/sur.2006.7.s2-113] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Infected pancreatic necrosis (IPN) is one of the most severe complications of acute pancreatitis (AP). Sequential surgical debridement represents one of the most effective treatments in terms of morbidity and mortality. The aim of this paper is to describe the quality of life and long-term results (e.g., nutritional, muscular, and pancreatic function) of patients treated by sequential necrosectomy at the Department of Surgery of the University of Insubria (Varese, Italy). METHODS Data were collected on patients undergoing sequential surgical debridement as treatment for IPN. The severity of AP was evaluated using the Ranson criteria, the Acute Physiology and Chronic Health Evaluation (APACHE II) Score, and the Sepsis Score, as well as the extent of necrosis. The surgical approach was through a midline or subcostal laparotomy, followed by exploration of the peritoneal cavity, wide debridement, and peritoneal lavage. The abdomen was either left open or closed partially with a surgical zipper, with multiple re-laparotomies scheduled until debridement of necrotic tissue was complete. The long-term evaluation focused on late morbidity, performance status, and abdominal wall function. RESULTS In the majority of patients (68%), mixed flora were isolated. Pseudomonas aeruginosa was the microorganism identified most commonly (59%), often associated with Candida albicans or C. glabrata. The mean total hospital stay was 71+/-38 days (range 13-146 days), of which 24+/-19 days (range 0-66 days) were in the intensive care unit. Eight patients died, the deaths being caused by multiple organ dysfunction syndrome in seven patients and hemorrhage from the splenic artery in one. Normal exocrine and endocrine pancreatic function was observed in 28 patients (88%). At discharge, four patients had steatorrhea, which was temporary. Eight patients (23%) developed pancreatic pseudocysts, and in six, cystogastostomy was performed. Most patients (29/32, 91%) developed a post-operative hernia, but only five required surgical repair. All patients had a Short Form (SF)-36 score>60%, and 20 of the 32 patients (68%) had scores>70-80% (good quality of life). The worst scores were related to alcoholic pancreatitis. CONCLUSIONS The degree of pancreatic failure (exocrine and endocrine function) is not related to the amount of pancreatic necrosis. Even with a need for repeated laparotomy and multiple surgical procedures, the abdominal wall capacity as well as long-term quality of life remain excellent.
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Meier R, Ockenga J, Pertkiewicz M, Pap A, Milinic N, Macfie J, Löser C, Keim V. ESPEN Guidelines on Enteral Nutrition: Pancreas. Clin Nutr 2006; 25:275-84. [PMID: 16678943 DOI: 10.1016/j.clnu.2006.01.019] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2006] [Accepted: 01/21/2006] [Indexed: 12/11/2022]
Abstract
The two major forms of inflammatory pancreatic diseases, acute and chronic pancreatitis, require different approaches in nutritional management, which are presented in the present guideline. This clinical practice guideline gives evidence-based recommendations for the use of ONS and TF in these patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. In mild acute pancreatitis enteral nutrition (EN) has no positive impact on the course of disease and is only recommended in patients who cannot consume normal food after 5-7 days. In severe necrotising pancreatitis EN is indicated and should be supplemented by parenteral nutrition if needed. In the majority of patients continuous TF with peptide-based formulae is possible. The jejunal route is recommended if gastric feeding is not tolerated. In chronic pancreatitis more than 80% of patients can be treated adequately with normal food supplemented by pancreatic enzymes. 10-15% of all patients require nutritional supplements, and in approximately 5% tube feeding is indicated.
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Affiliation(s)
- R Meier
- Department of Gastroenterology, Kantonsspital Liestal, Liestal, Switzerland.
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Abstract
The pancreas plays a major role in nutrient digestion. Therefore, in both acute and chronic pancreatitis, exocrine and endocrine pancreatic insufficiency can develop, impairing digestive and absorptive processes. These changes can lead to malnutrition over time. In parallel to these changes, decreased caloric intake and increased metabolic activity are often present. Nutritional deficiencies negatively affect outcome if they are not treated. Nutritional assessment and the clinical severity of the disease are important for planning any nutritional intervention. In severe acute pancreatitis, enteral nutrition with a naso-jejunal feeding tube and a low molecular diet displays clear advantages compared to parenteral nutrition. Infectious complications, length of hospital stay and the need for surgery are reduced. Furthermore, enteral nutrition is less costly than parenteral nutrition. Parenteral nutrition is reserved for patients who do not tolerate enteral nutrition. Abstinence from alcohol, dietary modifications and pancreatic enzyme supplementation is sufficient in over 80% of patients with chronic pancreatitis. In addition, oral supplements are helpful. Enteral nutrition can be necessary if weight loss continues. Parenteral nutrition is very seldom used in patients with chronic pancreatitis.
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Affiliation(s)
- Rémy F Meier
- GI-Unit, University Hospital Liestal, Kantonsspital Liestal, CH-4410 Liestal, Switzerland.
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10
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Connor S, Ghaneh P, Raraty M, Rosso E, Hartley MN, Garvey C, Hughes M, McWilliams R, Evans J, Rowlands P, Sutton R, Neoptolemos JP. Increasing age and APACHE II scores are the main determinants of outcome from pancreatic necrosectomy. Br J Surg 2004; 90:1542-8. [PMID: 14648734 DOI: 10.1002/bjs.4341] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The aim of this study was to identify factors associated with death after surgery in patients with extensive pancreatic necrosis. METHODS Sixty-four patients who underwent pancreatic necrosectomy between 1996 and 2002 were studied. RESULTS The median age was 60.5 (95 per cent confidence interval (c.i.) 57 to 64) years and 40 patients (62.5 per cent) were tertiary referrals. The initial median Acute Physiology And Chronic Health Evaluation (APACHE) II score was 9 (95 per cent c.i. 7.9 to 10.1) and there were 21 deaths (32.8 per cent). Twenty-eight patients (43.8 per cent) underwent minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) and the remainder had open pancreatic necrosectomy (OPN); 44 (72.1 per cent) of 61 patients had infected pancreatic necrosis at the time of the first procedure. Seven patients who underwent MIRP died compared with 14 after OPN (P = 0.240). Patients who died were older than those who survived, with higher APACHE II scores at presentation, and before and after surgery (P = 0.001). Survivors had significantly longer times to surgery than those who died (P = 0.038). All 21 patients who died required intensive care compared with 26 of 43 survivors (P < 0.001). Thirty of 36 patients who had the OPN procedure required intensive care compared with only 17 of 28 patients who had MIRP (P = 0.042). Logistic regression analysis showed that only postoperative APACHE II score was an independent predictor of increased mortality (P = 0.031). CONCLUSION Advanced age and increasing APACHE II score, and a need for postoperative intensive care, were the most important predictors of outcome after pancreatic necrosectomy.
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Affiliation(s)
- S Connor
- Department of Surgery, Royal Liverpool University Hospital, 5th floor UCD Building, Daulby Street, Liverpool L69 3GA, UK
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Connor S, Ghaneh P, Raraty M, Sutton R, Rosso E, Garvey CJ, Hughes ML, Evans JC, Rowlands P, Neoptolemos JP. Minimally invasive retroperitoneal pancreatic necrosectomy. Dig Surg 2003; 20:270-7. [PMID: 12748429 DOI: 10.1159/000071184] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Open surgery for pancreatic necrosis is associated with considerable morbidity and mortality. We report the results of a recently developed minimally invasive technique that we adopted in 1998. METHODS A descriptive explanation of the approach is given together with the results of a retrospective analysis of patients who underwent a minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) between August 1998 and April 2002. PATIENTS There were 24 patients with a median (range) age of 61 (29-75) years. The initial median (range) APACHE II score was 8 (2-21). All patients had infected pancreatic necrosis with at least 50% pancreatic necrosis. In three patients it was not possible to complete the first MIRP because of technical reasons. RESULTS A total of 88 procedures were performed with a median (range) of 4 (0-8) per patient. Twenty-one (88%) patients developed 36 complications during the course of their illness. Five patients required an additional open procedure: 2 for subsequent distant collections, 2 for bleeding and 1 for persisting sepsis and a distant abscess. Six (25%) patients who had MIRP died. The median (range) post-operative hospital stay was 51 (5-200) days. CONCLUSIONS MIRP is a new technique that has shown promising results, and could be preferable to open pancreatic necrosectomy in selected patients. However, unresolved issues remain to be overcome and the exact role of MIRP in the management of pancreatic necrosis has yet to be defined.
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Affiliation(s)
- S Connor
- Department of Surgery, Royal Liverpool University Hospital, Liverpool, UK
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Liu TH, Kwong KL, Tamm EP, Gill BS, Brown SD, Mercer DW. Acute pancreatitis in intensive care unit patients: value of clinical and radiologic prognosticators at predicting clinical course and outcome. Crit Care Med 2003; 31:1026-30. [PMID: 12682467 DOI: 10.1097/01.ccm.0000049951.77583.85] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To assess the value of clinical and/or radiographic prognostic indices in predicting the clinical course and outcome of patients with acute pancreatitis, in the intensive care unit. DESIGN Retrospective, single institution review. SETTING An adult medical and surgical intensive care unit in a public, urban teaching hospital. PATIENTS Patients with acute pancreatitis requiring intensive care unit admission between January 1, 1997 and June 30, 2000. INTERVENTIONS Standard care. MEASUREMENTS AND MAIN RESULTS A total of 477 patients were hospitalized with the diagnosis of acute pancreatitis. Of these, 28 patients (6%) were admitted to the intensive care unit. Ranson's, Imrie scores, Acute Physiologic and Chronic Health Evaluation (APACHE) II and III scores, simplified acute physiology scores, and multiple organ dysfunction scores were tabulated at 1, 2, 3, 7, and 14 days after intensive care unit admission. Abdominal computed tomography was available for review for 24 of the 28 patients (86%), where the mean Balthazar's computed tomography index was 4.5 +/- 0.4 (range = 2 to 10). Hospital mortality rate for the intensive care unit patients was 14% (4 of 28). The intensive care unit length of stay ranged from 1 to 79 days (mean 15 days, median 5 days). Fifty-seven percent of the patients developed organ dysfunction, and 36% of the patients required mechanical ventilatory support, ranging in duration from 1 to 70 days. Infectious morbidity occurred in 43% of patients. Thirty-six percent of the patients required operative intervention for intraabdominal complications. APACHE II scores at 7 days after intensive care unit admission correlated closely with ventilator days (r2 =.90; p =.003) and correlated with the occurrence of infectious complications (r2 =.71; p =.02). Patient age, APACHE III, simplified acute physiology scores, multiple organ dysfunction scores, Ranson, Imrie, computed tomography, and APACHE II scores before day 7 did not closely correlate with the occurrence of adverse clinical outcome. CONCLUSIONS The clinical course and outcomes of intensive care unit patients with acute pancreatitis can be highly variable. An APACHE II score <10 during the initial 48 hrs correlated with mild pancreatitis and uncomplicated intensive care unit course; however, multifactorial prognosticators were not useful for the early identification of patients who developed complications or required extended intensive care unit care.
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Affiliation(s)
- Terrence H Liu
- Departments of Surgery, The University of Texas-Houston Medical School and Lyndon B. Johnson General Hospital, Houston, TX, USA.
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Hungness ES, Robb BW, Seeskin C, Hasselgren PO, Luchette FA. Early debridement for necrotizing pancreatitis: is it worthwhile? J Am Coll Surg 2002; 194:740-4; discussion 744-5. [PMID: 12081064 DOI: 10.1016/s1072-7515(02)01182-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The timing for debridement of necrotizing pancreatitis is controversial. We reviewed our experience with early and delayed surgical debridement in patients with necrotizing pancreatitis. STUDY DESIGN The records of patients diagnosed with acute necrotizing pancreatitis from January 1993 through June 2000 were reviewed retrospectively. Data were analyzed with respect to Ranson's, APACHE II, and multiple organ failure scores, etiology, presence of infection, overall and ICU length of stay, time to first debridement, number of debridements, fluid requirements, days to enteral feeding, transfusion requirements, complications, and mortality. RESULTS Twenty-six patients (18 males, 8 females, mean age 51 years) were diagnosed with acute necrotizing pancreatitis. The admission Ranson's score was 4.8, the APACHE II score was 11.7, and multiple organ failure score was 4.2. All but one patient underwent pancreatic debridement (4.3 debridements per patient). Eighteen patients (69%) had infected pancreatic necrosis. The timing of debridement was based on patients' condition and surgeon's preference. The presentation and demographics of patients who underwent early (<2 weeks) or late (>2 weeks) debridement did not differ significantly. Patients debrided early had a trend toward higher mortality (29% versus 18%) and experienced a higher number of major complications (p < 0.05). The six patients (23%) who died were older, had multiple organ failure scores, and more often had Candida in the infected necrosis (p < .05). CONCLUSIONS Early debridement for acute necrotizing pancreatitis might not improve survival and might even be associated with increased number of complications. Most patients diagnosed with necrotizing pancreatitis eventually need debridement, but it might be beneficial to delay debridement if the patient's condition allows for it.
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Affiliation(s)
- Eric S Hungness
- Department of Surgery, University of Cincinnati Medical Center, OH, USA
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14
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Zazzo JF. Modalités de la nutrition artificielle au cours des pancréatites aiguës. NUTR CLIN METAB 2001. [DOI: 10.1016/s0985-0562(01)00072-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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O’Neill S, O’Neill AJ, Conroy E, Brady HR, Fitzpatrick JM, Watson RWG. Altered caspase expression results in delayed neutrophil apoptosis in acute pancreatitis. J Leukoc Biol 2000. [DOI: 10.1189/jlb.68.1.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Sean O’Neill
- Department of Surgery and Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin and Mater Misericordiae Hospital, Dublin 7, Ireland
| | - Amanda J. O’Neill
- Department of Surgery and Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin and Mater Misericordiae Hospital, Dublin 7, Ireland
| | - Eimear Conroy
- Department of Surgery and Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin and Mater Misericordiae Hospital, Dublin 7, Ireland
| | - Hugh R. Brady
- Department of Surgery and Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin and Mater Misericordiae Hospital, Dublin 7, Ireland
| | - John. M. Fitzpatrick
- Department of Surgery and Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin and Mater Misericordiae Hospital, Dublin 7, Ireland
| | - R. William G. Watson
- Department of Surgery and Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin and Mater Misericordiae Hospital, Dublin 7, Ireland
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Abstract
We describe a patient with infected pancreatic necrosis who was treated successfully with minimally invasive surgery. Five weeks after an episode of acute uncomplicated pancreatitis, he was found to have infected pancreatic necrosis and splenic vein thrombosis. The patient underwent a laparoscopic pancreatic necrosectomy, splenectomy, and cholecystectomy. Seven days after surgery, the patient was discharged and continued to be asymptomatic for the 6 months of follow-up.
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Affiliation(s)
- G G Hamad
- Department of Surgery, Medical College of Virginia/Virginia Commonwealth University, Richmond, USA.
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17
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Abstract
In acute pancreatitis, pancreatic inflammation may be complicated by the development of pancreatic infection with a high associated mortality. Pancreatic infection is related to the extent of pancreatic inflammation and necrosis and typically occurs in the second or third week of severe disease. It may be associated with a wide range of Gram-positive and Gram-negative bacteria, notably enterobacteria and also with Candida spp. Current surgical practice in the UK is to use prophylactic antimicrobial therapy in patients with severe disease, with the aim of preventing secondary pancreatic infection. Experimental evidence demonstrates that prophylactic antibacterial therapy prevents pancreatic infection and reduces mortality. Furthermore, studies of antibacterial prophylaxis in patients with acute pancreatitis suggest that prophylactic antibacterial therapy is associated with a reduction in mortality, particularly in those with severe disease. In general, broad-spectrum antibiotics have been used in animal and human studies. However, current evidence does not allow comparisons to be made between different antimicrobial agents. Nutritional strategies may also be important in the prevention of pancreatic infection. Enteral, rather than parenteral, nutrition has been associated with an improved clinical outcome in severe pancreatitis.
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Affiliation(s)
- A O Qamruddin
- Department of Microbiology, Salford Royal Hospitals NHS Trust, Hope Hospital, Salford, M6 8HD
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