ACUTE NECROTISING PANCREATITIS:TREATMENT STRATEGY ACCORDING TO THE STATUS OF INFECTION - University of Bern,Switzerland -Annals of Surgery,2000 Presented by : Dr.Abdulrahman Algarni

Objective to determine benefits of conservative versus surgical treatment in patients with necrotising pancreatitis

Background infection of pancreatic necrosis is the most important risk factor contributing to death in severe acute pancreatitis,and it is generally accepted that infected pancreatic necrosis should be managed surgically.

In contrast,the management of sterile pancreatic necrosis with organ failure is controversial.

Methods between Jan 1994 and June 1999, 204 consecutive patients with acute panc were recruited prospectively.

Inclusion criteria: elevation of amylase more than three times normal and typical clinical picture.

NP was defined by contrast- enhanced CT and CRP (>150mg/L). On admission all patients were treated medically.

Clinical severity staging of acute panc was carried out using the Ranson and APACHE II score.

Antibiotic was given less than 24 hr after CT findings of necrosis in patients with NP.

In NP Pt,CT-guided (FNA) with GS\CS was carried out if infection of necrosis was clinically suspected

Indications were :newly developed signs of metabolic disorders and deterioration of organ failures of lung, kidney,or CVS. Newly increase of WBC or fever(>38.5).

Complete FU was carried out (35months)after discharge. P<.05 was considered significant.

RESULTS 204 patients were in the study.

In EP patients non had multiple organ failure,but in 12 pt (10%) single organ failure was diagnosed(1 renal,4 pul,3 CVS,4 metabolic disorder)

Readmission in 7pt (6%)after 8.3 month for: recurrent acute panc (n=4),duodenal obs(n=1),and pseudocyst (n=1).

In NP,single and multiple organ failure occurred in 32 and 30 pt,respectively

In pt with Sterile necrosis 56/57 pt were managed conservatively.

Follow-up during the study period 11patients(19%) were readmitted to the hospital after a mean of 6.9 months for various pancreatitis- related

complication such as recurrent pancreatitis (n=4),pancreatic pseudocyst (n=4),duodenal obstruction(n=2), and splenic vein thrombosis (n=1 )

Infected necrosis overall,27of 28 patients (96%) were correctly diagnosed as having infected necrosis

Surgical treatment a total of 27 patients with infected necrosis underwent necrosectomy and subsequent continuous 1avage of the necrotic cavity by means of double-lumen drainage tubes.

Follow-up during the study period 7patients (32%) were readmitted after a mean of 4 month for pancreatitis-related complications:persistent pancreatic fistula(n=3),recurrent pancreatitis (n=1), pancreatic pseudocyst (n=1), pancreatic abscess (n=1),and chronic pain(n=1).

Discussion the study demonstrates and confirms that conservative treatment of sterile necrosis using early antibiotics is safe and effective.

The prevalence of pancreatic infection in NP could be lowered if antibiotics were given early

If antibiotics is successful in preventing infection,surgery in NP might not be able to achieve a better goal than conservative treatment

Surgery remains the gold standard in the treatment of infected pancreatic necrosis,and debridement and continuous closed lavage was successful in 67% of the patients with infected necrosis.

Delaying surgery(more than 3 weeks) until demarcation of pancreatic necrosis is also reported by others.

Conclusion these results support nonsurgical management, including early antibiotic treatment,in patients with sterile pancreatic necrosis. Patients with infected necrosis still represent a high-risk group in severe acute pancreatitis,and for them surgical treatment seems preferable.

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