Necrotizing Pancreatitis - Surgery

1/9/2008

Question:  For a patient with acute necrotizing pancreatitis, what is the likelihood of repeated surgical interventions?

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Unique Identifier [PMID]: 18086987

Authors: Besselink MG. Verwer TJ. Schoenmaeckers EJ. Buskens E. Ridwan BU. Visser MR. Nieuwenhuijs VB. Gooszen HG.

Institution: Department of Surgery, University Medical Center Utrecht, Room G.04.228, PO Box 85500, 3508 GA Utrecht, The Netherlands.

Title: Timing of surgical intervention in necrotizing pancreatitis.

Source: Archives of Surgery. 142(12):1194-201, 2007 Dec.

Abstract: OBJECTIVE: To determine the effect of timing of surgical intervention for necrotizing pancreatitis. DESIGN: Retrospective study of 53 patients and a systematic review. SETTING: A tertiary referral center. Main Outcome Measure Mortality. RESULTS: Median timing of the intervention was 28 days. Eighty-three percent of patients had infected necrosis and 55% had preoperative organ failure. The mortality rate was 36%. Sixteen patients were operated on within 14 days of initial admission, 11 patients from day 15 to 29, and 26 patients on day 30 or later. This latter group received preoperative antibiotics for a longer period (P < .001), and Candida species and antibiotic-resistant organisms were more often cultured from the pancreatic or peripancreatic necrosis in these patients (P = .02). The 30-day group also had the lowest mortality (8% vs 75% in the 1 to 14-days group and 45% in the 15 to 29-days group, P < .001); this difference persisted when outcome was stratified for preoperative organ failure. During the second half of the study, necrosectomy was further postponed (43 vs 20 days, P = .06) and mortality decreased (22% vs 47%, P = .09). We also reviewed 11 studies with a total of 1136 patients. Median surgical patient volume was 8.3 patients per year (range, 5.3-15.6), median timing of surgical intervention was 26 days (range, 3-31), and median mortality was 25% (range, 6%-56%). We observed a significant correlation between timing of intervention and mortality (R = - 0.603; 95% confidence interval, - 2.10 to - 0.02; P = .05). CONCLUSION: Postponing necrosectomy until 30 days after initial hospital admission is associated with decreased mortality, prolonged use of antibiotics, and increased incidence of Candida species and antibiotic-resistant organisms.

Publication Type: Journal Article. Research Support, Non-U.S. Gov't.

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Unique Identifier [PMID]: 17522520

Authors: Papachristou GI. Takahashi N. Chahal P. Sarr MG. Baron TH.

Institution: Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.

Title: Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis.

Source: Annals of Surgery. 245(6):943-51, 2007 Jun.

Abstract: BACKGROUND: Experience with minimal access, transoral/transmural endoscopic drainage/debridement of walled-off pancreatic necrosis (WOPN) after necrotizing pancreatitis is limited. We sought to determine outcome using this technique. METHODS: Retrospective analysis. RESULTS: From 1998 to 2006, 53 patients underwent transoral/transmural endoscopic drainage/debridement of sterile (27, 51%) and infected (26, 49%) WOPN. Intervention was performed a median of 49 days (range, 20-300 days) after onset of acute necrotizing pancreatitis. A median of 3 endoscopic procedures/patient (range, 1-12) were performed. Twenty-one patients (40%) required concurrent radiologic-guided catheter drainage of associated or subsequent areas of peripancreatic fluid and/or WOPN. Twelve patients (23%) required open operative intervention a median of 47 days (range, 5-540) after initial endoscopic drainage/debridement, due to persistence of WOPN (n = 3), recurrence of a fluid collection (n = 2), cutaneous fistula formation (n = 2), or technical failure, persistence of pancreatic pain, colonic obstruction, perforation, and flank abscess (n = 1 each). Final outcome after initial endoscopic intervention (median, 178 days) revealed successful endoscopic therapy in 43 (81%) and persistence of WOPN in 10 (19%). Preexistent diabetes mellitus, size of WOPN, and extension of WOPN into paracolic gutter were significant predictive factors for need of subsequent open operative therapy. CONCLUSIONS: Successful resolution of symptomatic, sterile, and infected WOPN can be achieved using a minimal access endoscopic approach. Adjuvant percutaneous drainage is necessary in up to 40% of patients, especially when WOPN extends to paracolic gutters or pelvis. Operative intervention for failed endoscopic treatment is required in about 20% of patients.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 17458611

Authors: Ocampo C. Oria A. Zandalazini H. Silva W. Kohan G. Chiapetta L. Alvarez J.

Institution: Department of Surgery, Cosme Argerich Hospital, Ayacucho 1485, Ciudad de Buenos Aires, Argentina. ocampoc@yahoo.com

Title: Treatment of acute pancreatic pseudocysts after severe acute pancreatitis.

Source: Journal of Gastrointestinal Surgery. 11(3):357-63, 2007 Mar.

Abstract: Treatment of acute pancreatic pseudocysts (APP) after an episode of severe acute pancreatitis (SAP) remains controversial. Both population heterogeneity and limited numbers of patients in most series prevent a proper analysis of therapeutic results. The study design is a case series of a large, tertiary referral hospital in the surgical treatment of patients with APP after SAP. An institutional treatment algorithm was used to triage patients with complicated APP and organ failure based on Sequential Organ Failure Assessment scores to temporizing percutaneous or endoscopic drainage to control sepsis and improve their clinical condition before definitive surgical management. Over a 10-year period of study (December 1995 to 2005), 73 patients with APP after an episode of SAP were treated, 43 patients (59%) developed complications (infection 74.4%, perforation 21%, and bleeding 4.6%) and qualified for our treatment algorithm. Percutaneous/endoscopic drainage was successful in controlling sepsis in 11 of 13 patients (85%) with severe organ failure and allowed all patients to undergo definitive surgical management. The morbidity (7 vs 44.1%, P = 0.005) and mortality rates (0 vs 19%, P = 0.04) were significantly higher in complicated vs uncomplicated APP. Acute pancreatic pseudocysts after SAP are unpredictable and have a high incidence of complications. Once complications develop, there is a significantly higher morbidity and mortality rate. In complicated APP with severe organ failure, percutaneous/endoscopic drainage is useful in controlling sepsis and allowing definitive surgical management.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 17446837

Authors: Lee JK. Kwak KK. Park JK. Yoon WJ. Lee SH. Ryu JK. Kim YT. Yoon YB.

Institution: Department of Internal Medicine, Dongguk University International Hospital, Dongguk University College of Medicine, Goyang, Korea.

Title: The efficacy of nonsurgical treatment of infected pancreatic necrosis.

Source: Pancreas. 34(4):399-404, 2007 May.

Abstract: OBJECTIVES: We conducted this study to evaluate the efficacy of nonsurgical treatment for patients with infected pancreatic necrosis (IPN). METHODS: Among 224 patients with acute pancreatitis from 2000 to 2004, there were 31 patients diagnosed as having IPN complication. The diagnostic criteria for IPN were either a positive culture or free gas in the pancreas of patients with acute pancreatic necrosis. Nonsurgical management including percutaneous drainage or endoscopic drainage (ED) followed by vigorous irrigation was initially attempted in all patients. Surgery was planned only when there was no clinical improvement after the initial nonsurgical treatment. RESULTS: Percutaneous drainage or ED was performed in 18 and 5 patients, respectively. Eight patients received antibiotics only. Four patients (12.9%) (3 from percutaneous drainage group and 1 from ED group) required surgery. Sepsis or fistula developed in 32% and 6% of patients, respectively, and was managed successfully. One patient (3.2%) died as a result of rapidly progressing multiorgan failure. The mean duration of hospitalization was 37 days. During the follow-up period, 7 patients were readmitted because of fever; they were managed by reposition of the drainage tube. CONCLUSIONS: Intensive nonsurgical treatment is very effective and safe and should be considered as an initial treatment modality for patients with IPN.

Publication Type: Journal Article. Research Support, Non-U.S. Gov't.

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Unique Identifier [PMID]: 17106218

Authors: Andersson B. Olin H. Eckerwall G. Andersson R.

Institution: Department of Surgery, Lund University Hospital, Lund, Sweden.

Title: Severe acute pancreatitis--outcome following a primarily non-surgical regime.

Source: Pancreatology. 6(6):536-41, 2006.

Abstract: BACKGROUND/AIMS: Severe acute pancreatitis (SAP) is associated with a high morbidity and mortality. The aim was to evaluate treatment, risk factors and outcome in SAP in a centre with a restrictive attitude to surgery. METHODS: All cases of acute pancreatitis admitted 1994-2003 were analysed retrospectively. SAP was defined as organ failure and/or hospital stay >7 days together with one or more of: C-reactive protein >150 mg/l within 72 h after admission, necrosis on computed tomography and need for treatment in the intensive care unit. RESULTS: 185 (22%) of patients with acute pancreatitis fulfilled the criteria for SAP. 175 patients were included, mean age 61 +/- 17 years. Hospital stay was in median 13 days. Forty-six patients had some surgical intervention, in 14 cases directed at the pancreas (8%). Hospital mortality was 9% (n = 16), in 88% (n = 14) associated with multiple organ dysfunction and 50% (n = 8) of the deaths occurred within the first week after admission. Of the parameters registered on admission, age and hypotension (systolic blood pressure <100 mm Hg) were identified as risk factors for death. CONCLUSION: The present treatment regime for SAP as defined above resulted in a 9% mortality rate, with age and hypotension at admission as predictive factors for death. Copyright 2006 S. Karger AG, Basel and IAP.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 17103098

Authors: Remes-Troche JM. Uscanga LF. Pelaez-Luna M. Duarte-Rojo A. Gonzalez-Balboa P. Teliz MA. Chan-Nunez C. Campuzano M. Robles-Diaz G.

Institution: Department of Gastroenterology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga # 15, Colonia Seccion XVI, Tlalpan, CP 14000, Mexico City, Mexico.

Title: When should we be concerned about pancreatic necrosis? Analysis from a single institution in Mexico City.

Source: World Journal of Surgery. 30(12):2227-33; discussion 2234-5, 2006 Dec.

Abstract: BACKGROUND/AIM: Although pancreatic necrosis classifies acute pancreatitis (AP) as severe, many patients with tomographic evidence of necrosis never develop systemic complications. Our aim was to analyze the incidence of pancreatic necrosis, organ failure (OF), and the relationship between them. METHODS: Medical records from 165 patients with a first AP episode and in whom a contrast-enhanced computed tomography (CECT) was performed were analyzed. Pancreatic necrosis was diagnosed as non-enhancing areas of the pancreas on the CECT and was graded as <30%, 30%-50%, and >50%. Pancreatic infection was assessed by guided percutaneous aspiration. Organ failure was defined according to the Atlanta criteria. RESULTS: Of 165 patients (mean age 42 years, 85 men), 54 (33%) had pancreatic necrosis. Necrosis was graded as <30% in 25 subjects (46%), 30%-50% in 16 (30%), and >50% in 13 (24%). Pancreatic infection was diagnosed in 14 cases (26%). Organ failure occurred in 49 patients: in 20 patients (37%) with necrosis, and in 29 patients (26%) without necrosis (P = 0.20). Extensive pancreatic necrosis (>50%) (P < 0.05) and infected necrosis (P < 0.05) were significantly associated with OF. Eight patients, all of them with OF, died. In 6 of these cases infected pancreatic necrosis was present. CONCLUSIONS: Patients with pancreatic necrosis are not necessarily at risk of developing OF. However, it should be considered an important risk factor when the necrotizing process compromises more than 50% of the gland and is infected.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 16983033

Authors: Parekh D.

Institution: Department of Surgery, University of Southern California, Los Angeles, CA, USA. dparekh@surgery.usc.edu

Title: Laparoscopic-assisted pancreatic necrosectomy: A new surgical option for treatment of severe necrotizing pancreatitis.

Source: Archives of Surgery. 141(9):895-902; discussion 902-3, 2006 Sep.

Abstract: HYPOTHESIS: Open surgery for pancreatic debridement is often associated with major morbidity such as wound complications, fascial dehiscence, and intestinal fistulae. Hand-assisted laparoscopic surgery (HALS) is useful for complex abdominal procedures since the benefits of traditional laparoscopic surgery are retained. Published experience with HALS for pancreatic debridement is limited to anecdotal case reports. SETTING: University-affiliated private and public hospitals. PATIENTS: Twenty-three patients with necrotizing pancreatitis were evaluated and 19 patients underwent pancreatic debridement from 2001 to 2006. A GelPort (Applied Medical, Rancho Santa Margarita, Calif) was used to provide laparoscopic hand access. In the majority of the patients, an infracolic approach was used to access the pancreatic necrosis. RESULTS: Nineteen patients underwent laparoscopic evacuation of pancreatic necrosis, and in 18 patients, the procedure was completed. The mean age was 54 years; the mean +/- SEM body mass index, calculated as weight in kilograms divided by height in meters squared, was 32.0 +/- 2.6; the mean American Society of Anesthesiologists score was 3.4; and 7 of 19 patients had past history organ failure. The mean +/- SEM operating time was 153 +/- 10 minutes and mean +/- SEM blood loss was 352.6 +/- 103 mL. Four patients required reoperations, 2 using HALS and 2 open. There were no postoperative complications related to the HAL procedure itself, such as major wound infections, intestinal fistulae, or postoperative hemorrhage. Postoperative computed tomographic scans confirmed adequacy of debridement. The mean +/- SEM length of hospital stay after surgery was 16.3 +/- 3.8 days. CONCLUSIONS: This is the largest reported study of laparoscopic debridement for pancreatic necrosis. The procedure is feasible and associated with a low morbidity and mortality. Pancreatic debridement with HALS may provide a new option for the surgical treatment of selected patients with severe necrotizing pancreatitis.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 16916387

Authors: Reddy M. Jindal R. Gupta R. Yadav TD. Wig JD.

Institution: Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

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

Source: ANZ Journal of Surgery. 76(8):704-9, 2006 Aug.

Abstract: BACKGROUND: Pancreatic necrosectomy for necrotizing pancreatitis is a formidable operation. There are limited data from the Indian subcontinent regarding outcome and recent trends in management. METHODS: Patients undergoing pancreatic necrosectomy over a 12-year period were identified from a prospective database. Data regarding the hospital course, complications and outcome were extracted by case file review. Descriptive statistics were used to present the data. An attempt was made to identify trends in management and outcome over the study period. RESULTS: One hundred and eighteen patients underwent necrosectomy. The median age was 39.5 years (interquartile range, 32-46). Median Acute Physiology And Chronic Health Evaluation II score at admission was 8 (interquartile range, 6-10). Thirty-nine patients (33%) had organ failure at admission. Patients underwent surgery a median of 23 days (interquartile range, 14-34) after onset of illness. There was high incidence of loco-regional complications (68/118, 58%) and organ failure (88/118, 75%) in the postoperative period. The mortality rate was 38%. There was an increase in the median onset to surgery interval (17 vs 25.5 days; P = 0.001), increased use of percutaneous interventions (20 vs 36%; P = 0.05) and decreased mortality (47 vs 29%; P = 0.052) in the later half of the study period. CONCLUSION: Pancreatic necrosectomy continues to be associated with significant morbidity and mortality in India. A trend towards increased use of percutaneous interventions and delayed surgery is evident.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 16895491

Authors: Cinquepalmi L. Boni L. Dionigi G. Rovera F. Diurni M. Benevento A. Dionigi R.

Institution: Department of Surgical Sciences, University of Insubria, Varese, Italy.

Title: Long-term results and quality of life of patients undergoing sequential surgical treatment for severe acute pancreatitis complicated by infected pancreatic necrosis.

Source: Surgical Infections. 7 Suppl 2:S113-6, 2006.

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.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 16808204

Authors: Haan JM. Scalea TM.

Institution: University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore 21201, USA.

Title: Laparoscopic debridement of recurrent pancreatic abscesses in the hostile abdomen.

Source: American Surgeon. 72(6):511-4, 2006 Jun.

Abstract: Recurrent necrotizing pancreatitis in the frozen or hostile abdomen remains a challenge. Percutaneous drainage is useful in these cases but often fails if there is significant pancreatic necrosis. We describe a technique for laparoscopic drainage of necrotic pancreas. The preexisting percutaneous drainage tract was sequentially dilated and a working thoracoscope was placed via a Hasson cannula. A pulsatile irrigation system was used to open the cavity for visualization and to wash away obvious necrotic debris. Working sequentially using the irrigation jet flow for debridement and visualization, we opened the entire tract and debrided a majority of the necrotic tissue. A large drainage tube was placed to allow the egress of any residual infection. Three patients to date have been treated with the above technique with no intraoperative complications. All three patients did well initially postoperatively and had adequate drainage. One patient developed a delayed pancreatic pseudocyst. Laparoscopic debridement via percutaneous drainage tract is a useful technique in the hostile abdomen.

Publication Type: Case Reports. Journal Article.

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Unique Identifier [PMID]: 16484129

Authors: Lund H. Tonnesen H. Tonnesen MH. Olsen O.

Institution: Department of Surgical Gastroenterology D, Glostrup Hospital, University of Copenhagen and Clinical Unit of Health Promotion, Bispebjerg Hospital, Denmark. h.lund@dadlnet.dk

Title: Long-term recurrence and death rates after acute pancreatitis.

Source: Scandinavian Journal of Gastroenterology. 41(2):234-8, 2006 Feb.

Abstract: OBJECTIVE: The aim of this study was to compare long-term recurrence and death rates after a first episode of acute pancreatitis in patients with and without gallstones. Additionally, it was of interest to find out if there were factors predictive of readmission or death. MATERIAL AND METHODS: Over a period of 3 years (1995 to 1998), 155 patients admitted with a first attack of acute pancreatitis were included in the study. They followed a specific protocol (ultrasound within 24 h, laboratory tests, Ranson scoring and patients with severe pancreatitis computed tomography scans). In gallstones, pancreatitis, either ERCP or cholecystectomy, was performed at admission or in the case of the latter within 4 weeks. A follow-up was done in January 2002. RESULTS: Forty-one percent of the patients without gallstones were readmitted to hospital during the period of follow-up compared to 10% in the group of patients with gallstones. Using multivariate analysis, no factors were significantly predictive of readmission. CONCLUSIONS: We found an identical mortality rate of 15% in the two groups, the only predictive factor being age.

Publication Type: Comparative Study. Journal Article.

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Unique Identifier [PMID]: 14707392

Authors: Tzovaras G. Parks RW. Diamond T. Rowlands BJ.

Institution: Professorial Surgical Unit, Royal Victoria Hospital, Belfast, Northern Ireland, UK. gtzovaras@hotmail.com

Title: Early and long-term results of surgery for severe necrotising pancreatitis.

Source: Digestive Surgery. 21(1):41-6; discussion 46-7, 2004.

Abstract: BACKGROUND: Necrotising pancreatitis is a challenging problem for the surgeon, as it is associated with considerable morbidity and mortality. The indications, timing of surgical intervention and type of procedure continue to be debated in an effort to improve the outcome of this devastating disease process. METHODS: A retrospective analysis of early and long-term results in a series of 44 consecutive patients (34 men, 10 women, median age 46.5, range 13-74 years) who underwent necrosectomy for severe necrotising pancreatitis. In 16 patients necrosectomy and primary abdominal closure with drains was performed, 14 patients had planned staged necrosectomy and delayed abdominal closure with drains, and in 14 patients necrosectomy with open laparostomy was undertaken. RESULTS: There were 8 deaths (18%) and 14 cases (32%) of significant hospital morbidity (fistula 10, pseudocyst 2, renal failure 2). Variables which correlated with mortality were: high APACHE II score, acute renal failure requiring dialysis, and requirement for surgical intervention at an early stage (within the first two weeks). A total of 28 late complications occurred in 21 of the surviving patients (endocrine pancreatic insufficiency 10, exocrine pancreatic insufficiency 2, pseudocyst 2, chronic renal failure 2, incisional hernia 10, recurrent pancreatitis 1, and chronic pain 1). CONCLUSIONS: Low mortality can be achieved in patients with severe necrotizing pancreatitis with aggressive surgical intervention and careful perioperative management. Long-term morbidity remains high, and emphasises the need for prolonged follow-up. Copyright 2004 S. Karger AG, Basel

Publication Type: Journal Article.

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Unique Identifier [PMID]: 14696503

Authors: Endlicher E. Volk M. Feuerbach S. Scholmerich J. Schaffler A. Messmann H.

Institution: Department of Internal Medicine I, University of Regensburg, D-93042 Regensburg, Germany. esther.endlicher@klinik.uni-regensburg.de

Title: Long-term follow-up of patients with necrotizing pancreatitis treated by percutaneous necrosectomy.

Source: Hepato-Gastroenterology. 50(54):2225-8, 2003 Nov-Dec.

Abstract: BACKGROUND/AIMS: The objective of this follow-up study was to assess the long-term outcome of patients with infected necrotizing pancreatitis treated with percutaneous catheter drainage and necrosectomy. METHODOLOGY: Nine patients (median age 44 years, range 19-69) with infected pancreatic necrosis and catheter drainage for initial treatment were evaluated after a median follow-up of 30 months (range 15-52) with respect to quality of life (pain, diarrhea, fat intolerance), morphology and endocrine and exocrine pancreatic function. RESULTS: At follow-up all 9 patients (100%) were in good general condition with respect to quality of life. Only 2/9 (22%) patients had moderate to marked changes in computed tomography. There was mild to moderate exocrine dysfunction in 5/8 (63%) patients, 2/8 (25%) patients had a severe restriction of the exocrine pancreatic function; in one patient the serum pancreoaryl test was normal. An oral glucose tolerance test was performed in 6/9 patients, with a normal result in 3/6 (50%) patients. 2/6 (33%) patients had an impaired oral glucose tolerance test with metabolic pathogenesis. One patient with diabetes in the oral glucose tolerance test had a preexisting type II diabetes requiring insulin therapy since the onset of acute pancreatitis. In 3/9 (33%) patients an oral glucose tolerance test was not performed due to known preexisting diabetes. CONCLUSIONS: Percutaneous drainage of infected necrotizing pancreatitis has given good long-term results with regard to quality of life, endocrine and exocrine pancreatic function and may be an alternative to surgical treatment.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 12523596

Authors: Beattie GC. Mason J. Swan D. Madhavan KK. Siriwardena AK.

Institution: Dept. of Surgical and Clinical Sciences, Critical Care Unit, Royal Infirmary of Edinburgh, UK.

Title: Outcome of necrosectomy in acute pancreatitis: the case for continued vigilance.

Source: Scandinavian Journal of Gastroenterology. 37(12):1449-53, 2002 Dec.

Abstract: BACKGROUND: Surgery for pancreatic necrosis complicating acute severe pancreatitis carries a high risk of mortality and may be influenced by a range of variables including patterns of referral, case selection and quality of care. METHODS: An observational study of a consecutive series of 54 patients undergoing pancreatic necrosectomy in a specialist Hepatobiliary unit over an 8-year study period. Principal outcomes were organ dysfunction and physiological derangement in relation to surgery, microbial colonization of necrosis and relation to outcome, re-operation rates, requirement for peri-operative nutritional support, trends in mortality and survival analysis. RESULTS: Necrosectomy was associated with statistically significant deterioration in immediate postoperative organ dysfunction scores (ANOVA P < 0.01). Infected necrosis was present in 36 (68%). Fungal colonization of necrosis was present in 5 (9%). Mortality in this subgroup was 80% (4 deaths). There was no association between bacterial colonization of necrosis and death in this study (P = 0.77; Fisher exact test; relative risk 0.9,95% confidence interval 0.54-1.54). Twenty patients (37%) required further surgical intervention with an average of 1.5 surgical procedures per patient. Twenty-three patients (43%) died. Patient survival to discharge was best predicted by admission APACHE-II score with relative risk of death increasing 14% for each unit increase in APACHE-II score at admission. CONCLUSIONS: The results of the present study illustrate that there is no place for complacency in the surgical management of patients with severe acute pancreatitis. A clinical governance approach would promote pre-defined protocols between admitting hospitals and tertiary referral centres. Future research should target new interventions in patients with high admission APACHE-II scores in whom prognosis is particularly poor and explore the role of infection of necrotic tissue.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 12081064

Authors: Hungness ES. Robb BW. Seeskin C. Hasselgren PO. Luchette FA.

Institution: Department of Surgery, University of Cincinnati Medical Center, OH, USA.

Title: Early debridement for necrotizing pancreatitis: is it worthwhile?.

Source: Journal of the American College of Surgeons. 194(6):740-4; discussion 744-5, 2002 Jun.

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.

Publication Type: Journal Article.

<16>

Unique Identifier [PMID]: 11910483

Authors: Gotzinger P. Sautner T. Kriwanek S. Beckerhinn P. Barlan M. Armbruster C. Wamser P. Fugger R.

Institution: Department of General Surgery, University of Vienna, AKH, Waehringer Guertel 18-20, 1090 Vienna, Austria. peter.goetzinger@akh-wien.ac.at

Title: Surgical treatment for severe acute pancreatitis: extent and surgical control of necrosis determine outcome.

Source: World Journal of Surgery. 26(4):474-8, 2002 Apr.

Abstract: In patients operated on for severe acute pancreatitis (SAP), the factors determining outcome remain unclear. From 1986 to 1998 a total of 340 patients with a diagnosis of SAP and in need of operative treatment were admitted to the intensive care unit (ICU) of a university hospital and a secondary care hospital. The mean APACHE II score on the day of admission was 16.1 (range 8-35). All patients required operative therapy. Among the 340 patients, 270 (79.4%) had to be reoperated: 196 patients (72.6%) underwent operative revisions on demand, and 74 (27.4%) patients had preplanned reoperation. The overall mortality was 39.1% (133 patients). Septic organ failure in 126 patients (37.1%) and myocardial infarction or pulmonary embolism in 7 patients (2%) were the causes of death. The patient's age (p < 0.0002), APACHE II scores at admission (p < 0.0001), presence or development of (single or multiple) organ failure (p < 0.002), infection (p < 0.02) and extent (p < 0.04) of pancreatic necrosis, and surgical control of local necrosis (p < 0.0001) significantly determined survival. SAP that requires surgical treatment is associated with high in-hospital mortality. Surgical control of local necrosis is the precondition for survival. Advanced age of the patient, high APACHE II score at admission, development of organ failure, and the extent and infection of pancreatic necrosis influence the outcome.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 10228845

Authors: Kasperk R. Riesener KP. Schumpelick V.

Institution: Department of Surgery, University Clinic RWTH Aachen, Germany.

Title: Surgical therapy of severe acute pancreatitis: a flexible approach gives excellent results.

Source: Hepato-Gastroenterology. 46(25):467-71, 1999 Jan-Feb.

Abstract: BACKGROUND/AIMS: To evaluate the effectiveness of our surgical strategy in acute and necrotizing pancreatitis we performed this prospective uncontrolled study. METHODOLOGY: Seventy-six patients with severe acute pancreatitis who were operated on between 1989 and 1995 were included in this study. Laparotomy aimed at removal of necrosis, treatment of ongoing necrosis, and correction of concurrent pathology were the principal goals of surgery. This required multiple interventions in 36 patients. RESULTS: Sixty-nine patients with a mean Ranson score of 3 survived, while 7 patients with a mean score of 7 died (9.2% overall mortality). Fifty-six patients (74%) underwent necrosectomy, followed by continuous lavage in 31 cases and laparostomy (provisional closure of abdominal cavity with absorbable mesh) with staged revisions in 14. Necroses were infected in 39% of initial operations. Twenty-two patients had to be re-operated without being scheduled for planned revisions, mostly for abscess formation, bleeding or intestinal ischemia. Mortality of necrotizing pancreatitis was 12.5%. CONCLUSIONS: Surgical therapy of acute necrotizing pancreatitis has to be tailored to the intra- and post-operative situations. In cases of massive or ongoing necrosis, the goal of surgical therapy will not be achieved by a singular intervention but has to be complemented with further treatment.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 9876068

Authors: Tsiotos GG. Luque-de Leon E. Sarr MG.

Institution: Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA.

Title: Long-term outcome of necrotizing pancreatitis treated by necrosectomy.

Source: British Journal of Surgery. 85(12):1650-3, 1998 Dec.

Abstract: BACKGROUND: Long-term functional outcome after operative treatment of necrotizing pancreatitis (NP) has not been studied extensively. METHODS: Pancreatic function, performance status, recurrence of symptoms and other related problems were analysed in 44 consecutive patients successfully discharged from hospital after operative necrosectomy (1983-1995) and followed up completely for a mean of 5 years. RESULTS: Clinical pancreatic insufficiency developed in half the patients. Diabetes mellitus (11 patients), steatorrhoea (six) or both (five) were associated with a mean estimate of 52, 66 and 67 per cent parenchymal necrosis respectively. Normal pancreatic function was associated with 27 per cent parenchymal necrosis (P < 0.05). Diabetes worsened while steatorrhoea tended to improve over time. Abdominal pain and pancreatitis recurred in six and two patients respectively. Performance status worsened in four patients because of recurrent pancreatitis and severe steatorrhoea. Poor long-term performance was associated with a higher Acute Physiology And Chronic Health Evaluation II score on admission (mean 14 versus 9). CONCLUSION: NP has prominent effects on long-term pancreatic exocrine and endocrine function in half the patients, but most preserve a good overall functional status. The development of pancreatic insufficiency varies with the extent of pancreatic parenchymal necrosis.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 9484724

Authors: Kriwanek S. Armbruster C. Dittrich K. Beckerhinn P. Schwarzmaier A. Redl E.

Institution: First Department of Surgery, Rudolfstiftung-Hospital, Vienna, Austria.

Title: Long-term outcome after open treatment of severe intra-abdominal infection and pancreatic necrosis.

Source: Archives of Surgery. 133(2):140-4, 1998 Feb.

Abstract: BACKGROUND: Outcome assessment after surgical treatment of intra-abdominal infections and pancreatic necrosis has concentrated on postoperative complications and survival, while long-term results have received little attention. OBJECTIVES: To evaluate hospital costs and long-term outcome for patients undergoing open treatment of intra-abdominal infection or pancreatic necrosis and to determine whether results justify costs. DESIGN: Cohort study and cost-effectiveness analysis. SETTING: Referral center. PATIENTS: From January 1, 1988, through June 30, 1996, we used open treatment for 147 patients with pancreatic necrosis (n=75; group 1), severe intra-abdominal infections due to benign diseases (n=50; group 2), and infections due to malignant neoplasm (n=22; group 3). All surviving patients (n=92) were followed up. Fifty-seven patients in group 1, 25 patients in group 2, and 10 patients in group 3 survived. INTERVENTIONS: The effective costs of treatment per surviving patient (including restorative surgery) were calculated. The patients were interviewed, and the residence location, medical treatment, degree of recovery, functional state, and employment status were assessed. We assessed the quality of life by using the short general health survey (SF-36). MAIN OUTCOME MEASURES: Costs, survival, and long-term outcome. RESULTS: The effective costs per survivor studied were $175000 (group 1) and $232400 (groups 2 and 3). Most patients experienced good long-term results, ie, employment status was unchanged for 69 (75%) of the patients, and the functional state was unchanged for 81 (88%) of the patients. Readmission to a hospital was necessary for 14 (15%) of the patients, and 5 (6%) required care in nursing homes. Of the patients studied, 75% described their quality of life as good. Patients in group 3 had significantly worse results for survival, functional status, and quality of life (P<.01, log-rank test). CONCLUSIONS: Our study demonstrated that open treatment of severe intra-abdominal infection and pancreatic necrosis is a cost-effective treatment with good long-term results for most patients. However, patients with malignant neoplasms did not benefit from this therapy and, therefore, should not be treated by laparostomy.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 9298914

Authors: van Goor H. Sluiter WJ. Bleichrodt RP.

Institution: Department of Surgery, University Hospital Groningen, The Netherlands.

Title: Early and long term results of necrosectomy and planned re-exploration for infected pancreatic necrosis.

Source: European Journal of Surgery. 163(8):611-8, 1997 Aug.

Abstract: OBJECTIVE: To evaluate the early and long term results of necrosectomy, planned re-explorations and open drainage in patients with infected pancreatic necrosis. DESIGN: Retrospective and case control study. SETTING: University hospital, The Netherlands. SUBJECTS: 10 patients with documented infected pancreatic necrosis (Balthazar D and E) and 6 matched healthy volunteers who served as controls for assessment of pancreatic endocrine function. INTERVENTIONS: Planned re-explorations 24-hourly until necrosis was completely removed. At follow-up after 3 years intravenous glucose tolerance test in surviving patients and in healthy volunteers. MAIN OUTCOME MEASURES: Mortality, intra-abdominal complications, long term pancreatic exocrine and endocrine function. RESULTS: Three patients died of multiple organ dysfunction. No patient developed a residual intra-abdominal abscess. Half of the patients developed complications including intra-abdominal haemorrhage, necrosis of the transverse colon and enterocutaneous fistula. One patient had steatorrhoea, another developed insulin dependent diabetes mellitus. Patients had impaired glucose tolerance but significantly (p < 0.05) raised glucagon and insulin concentrations compared with matched healthy volunteers. CONCLUSION: This treatment prevents residual intra-abdominal abscesses in patients with infected pancreatic necrosis but is associated with high morbidity. Surviving patients have impaired glucose tolerance, surprisingly accompanied by increased serum insulin and glucagon concentrations.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 8645040

Authors: Broome AH. Eisen GM. Harland RC. Collins BH. Meyers WC. Pappas TN.

Institution: Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.

Title: Quality of life after treatment for pancreatitis.[see comment].

Source: Annals of Surgery. 223(6):665-70; discussion 670-2, 1996 Jun.

Abstract: OBJECTIVE: The authors evaluated the morbidity, mortality, and quality of life after pancreatic debridement for necrosis and compared these values to those for quality of life after elective medical and surgical management for chronic pancreatitis. SUMMARY BACKGROUND DATA: Quality of life after pancreatic debridement for necrosis has received little attention. Although quality of life after other pancreatic surgery has been evaluated and is though to be good, management of patients with pancreatic necrosis can be labor intensive and require extraordinary resources. Therefore, further evaluation of the quality of life achieved after treatment is appropriate. METHODS: Forty patients (group 1) underwent operative debridement for necrosis between 1986 and 1994. Medical records of these patients were reviewed for morbidity, mortality, and in-hospital costs. Follow-up of quality of life was assessed by the Short Form-36 Health Survey. Patients in group 2 (n = 89) underwent medical management of chronic pancreatitis. Group 3 included 47 patients who underwent elective operations for ductal abnormalities. The Short Form-36 Health Surveys were administered to all three groups and compared statistically. RESULTS: Mortality and morbidity from pancreatic debridement was 18% and 77%, respectively. Quality-of-life evaluations in groups 1 through 3 and age-matched controls were statistically similar. CONCLUSIONS: Pancreatic debridement for necrosis requires intense application of resources and is associated with a high mortality and morbidity. Long-term follow-up shows good quality of life for patients who survive this morbid disease. This study supports the continued aggressive approach to the management of pancreatic necrosis, given that long-term outcome about quality of life is good.

Publication Type: Comparative Study. Journal Article.

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Unique Identifier [PMID]: 8243120

Authors: Huang YT. Liu Q. Zhang BS.

Institution: Department of General Surgery, First Teaching Hospital, Beijing Medical University.

Title: Long-term results of surgical treatment for acute hemorrhagic necrotizing pancreatitis.

Source: Chinese Medical Journal. 106(7):500-3, 1993 Jul.

Abstract: Eighteen patients with acute hemorrhagic necrotizing pancreatitis who survived from operation were followed up for 12 to 43 months. Late complications including pancreatic external fistula, pseudocyst, hyperglycemia, etc were reviewed. The pancreatic juice was collected through endoscopic cannulation. The volume and HCO3- concentration of the pancreatic juice and three kinds of pancreatic enzymes were measured. The results demonstrated that inspite of anatomic abnormality or functional impairment of the pancreas, the pancreatic insufficiency rarely manifested to be marked because of the compensative ability of the viable exocrine pancreas.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 8359555

Authors: Angelini G. Cavallini G. Pederzoli P. Bovo P. Bassi C. Di Francesco V. Frulloni L. Sgarbi D. Talamini G. Castagnini A.

Institution: Medical Clinic University of Verona, Italy.

Title: Long-term outcome of acute pancreatitis: a prospective study with 118 patients.

Source: Digestion. 54(3):143-7, 1993.

Abstract: 118 patients who had recovered from acute pancreatitis underwent endoscopic retrograde pancreatography (ERCP) during a long-term follow-up (mean 4.4 years, range 1-17) to investigate the frequency and features of residual ductal lesions. Oedematous and necrohaemorrhagic pancreatitis occurred in 35 and in 83 patients, respectively. The aetiology was biliary (39 patients), alcoholic (32), biliary-alcoholic (18) and miscellaneous (29). After oedematous pancreatitis, ERCP was normal in 31, showed obstructive pancreatitis in 2 and a slight localized and smooth stricture of the main duct in 2 patients. After necrotizing pancreatitis, 29 patients showed ductal changes without features of chronic pancreatitis, 7 obstructive, 3 chronic calcifying pancreatitis and 44 normal pictures. In 17 patients submitted to two or three ERCPs during a mean 10-year follow-up, the ductal appearance was unchanged in 12, worsened in 3, and improved in 2 patients. The aetiology of pancreatitis and frequency of recurrences was similar in patients with or without scarring lesions. We conclude that residual ductal lesions are common after acute necrotizing pancreatitis.

Publication Type: Journal Article. Research Support, Non-U.S. Gov't.

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Unique Identifier [PMID]: 1987854

Authors: Bradley EL 3rd. Allen K.

Institution: Department of Surgery, Emory University, Atlanta, Georgia.

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

Source: American Journal of Surgery. 161(1):19-24; discussion 24-5, 1991 Jan.

Abstract: 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.

Publication Type: Comparative Study. Journal Article.

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Unique Identifier [PMID]: 4041724

Authors: Nordback IH. Auvinen OA.

Title: Long-term results after pancreas resection for acute necrotizing pancreatitis.

Source: British Journal of Surgery. 72(9):687-9, 1985 Sep.

Abstract: This study was designed to investigate the long-term effects of early pancreatic resection for acute necrotizing pancreatitis. During 1973-1978 40 resections were performed in our clinic. Eleven patients died initially (28 per cent). None of the four further deaths was due to pancreatitis or associated disorders. Twenty-four patients were re-examined 5-11 years after resection--one patient refused to participate. Five had not been able to return to work because of severe polyneuropathy; one more had retired because of chronic pancreatitis in the pancreatic remnant. Polyneuropathy was found in five further patients. The reason for this high incidence of polyneuropathy (42 per cent) remains unknown. Eight patients still drank excessive alcohol; three of them had had recurrent pancreatitis and dyspepsia, and insulin requiring diabetes. All but 2 (92 per cent) had diabetes, 14 needing insulin--half of them at 6 months to 6 years after the resection. Moreover, 11 patients (46 per cent) suffered from dyspeptic symptoms. The results suggest that because of the high frequency of late complications, in addition to the early complications, early resection of pancreas should be critically re-evaluated as the treatment for acute necrotizing pancreatitis. If resection is used in patients with extreme pancreatic necrosis, careful and continuous postoperative follow-up will be needed.

Publication Type: Journal Article.