Comparisons of treatment strategies for necrotizing pancreatitis

Abstract

" Forty to seventy percent of secondary bacterial infections, mainly by Gram-negative organisms, can be combined with necrotizing pancreatitis, and it's mortality with organ failure is reported to be nearly 30%. Specific symptoms, contrast-enhanced abdominal computed tomography(CECT), Ranson's score, APACHE II score and confirmed infected necrosis by fine needle aspiration can be helpful for identifying diagnosis and disease severity. There have been controversies about conservative or operative treatment for necrotizing pancreatitis and surgical indications. Many studies in the literatures have shown infected necrosis as a definite surgical indication, similar to combined bowel perforation or massive uncontrolled intraabdominal hemorrhage.

In this retrospective report, 37 hospitalized patients who were diagnosed with necrotizing pancreatitis during the past 13 years were analyzed for therapeutic strategies, clinical course and results. Etiology and basic hemodynamic parameters, including pancreatic enzymes, CT severity index(CTSI), Ranson's score and APACHE II score, were analyzed. The incidence of pancreatic pseudocyst, pleural effusion, abdominal percutaneous lavage drainage, infected necrosis, organ failure and mortality rate, total hospital stay, the number of admission and length of stay in intensive care unit(ICU) were also identified.

All patients were routinely treated with prophylactic antibiotics, while 13 out of 37 patients were treated surgically. The etiologies included biliary(12), alcoholic(16) and others(9) such as postoperative, trauma and idiopathic. The rate of confirmed infected necrosis was 85.7%(6/7) in conservative treatment group and 100%(12/12) in surgical treatment group, showing significantly different etiology(p=0.001) between the two groups, and Ranson's score(p=0.025), APACHE II score(p=0.028), and total hospital stay(p=0.045), length of stay in ICU(p=0.019) were significantly higher in surgical treatment group. The mortality rates did not show any difference between the two groups(p=1.000). The timing of operation which was set up by 3 weeks resulted in no differences in clinical course and outcomes. There were also no differences between the two groups in clinical course and results in case of high Ranson's and APACHE II score, except the relation of high APACHE II score and length of stay in ICU(p=0.002).

This study showed that infected necrosis could not be surgical indication for necrotizing pancreatitis, because 6 patients fully recovered from the disease by only conservative treatment. Patients who were conservatively treated showed better clinical course and outcomes. Furthermore, Ranson's score or APACHE II score were not useful for deciding treatment strategy for necrotizing pancreatitis. Conservative treatment and cautious surgical observation should sincerely be considered for treatment of necrotizing pancreatitis."