Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg. 2008;247:294-299. [PMID: 18216536 DOI: 10.1097/sla.0b013e31815b6976]

Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis

BACKGROUND

The role of percutaneous catheter drainage (PCD) in patients with (infected) necrotizing pancreatitis was evaluated.

METHODS

A systematic literature search was performed. Inclusion criteria were: consecutive cohort of patients with necrotizing pancreatitis undergoing PCD as primary treatment for peripancreatic collections; indication for PCD either (suspected) infected necrosis or symptomatic sterile pancreatic necrosis; and outcomes reported to include percentage of infected peripancreatic collections, need for additional surgical necrosectomy, complications and deaths. Exclusion criteria were: cohort of fewer than five patients; cohort included patients with chronic pancreatitis; selected subgroup of patients with acute pancreatitis studied, such as those with pseudocysts, pancreatic abscesses and/or exclusively sterile pancreatic necrosis; and cohort in which PCD was combined with another minimally invasive strategy and results for PCD alone not reported separately.

RESULTS

Eleven studies, including 384 patients, fulfilled the inclusion criteria. Only one study was a randomized controlled trial; most others were retrospective case series. Four studies reported on the presence of organ failure before PCD; this occurred in 67·2 per cent of 116 patients. Infected necrosis was proven in 271 (70·6 per cent) of 384 patients. No additional surgical necrosectomy was required after PCD in 214 (55·7 per cent) of 384 patients. Complications consisted mostly of internal and external pancreatic fistulas. The overall mortality rate was 17·4 per cent (67 of 384 patients). Nine of 11 studies reported mortality separately for patients with infected necrosis undergoing PCD; the mortality rate in this group was 15·4 per cent (27 of 175).

CONCLUSION

A considerable number of patients can be treated with PCD without the need for surgical necrosectomy.

Dual-energy multidetector CT: how does it work, what can it tell us, and when can we use it in abdominopelvic imaging?

Dual-energy CT provides information about how substances behave at different energies, the ability to generate virtual unenhanced datasets, and improved detection of iodine-containing substances on low-energy images. Knowing how a substance behaves at two different energies can provide information about tissue composition beyond that obtainable with single-energy techniques. The term K edge refers to the spike in attenuation that occurs at energy levels just greater than that of the K-shell binding because of the increased photoelectric absorption at these energy levels. K-edge values vary for each element, and they increase as the atomic number increases. The energy dependence of the photoelectric effect and the variability of K edges form the basis of dual-energy techniques, which may be used to detect substances such as iodine, calcium, and uric acid crystals. The closer the energy level used in imaging is to the K edge of a substance such as iodine, the more the substance attenuates. In the abdomen and pelvis, dual-energy CT may be used in the liver to increase conspicuity of hypervascular lesions; in the kidneys, to distinguish hyperattenuating cysts from enhancing renal masses and to characterize renal stone composition; in the adrenal glands, to characterize adrenal nodules; and in the pancreas, to differentiate between normal and abnormal parenchyma.

Current Surgical Management of Infected Pancreatic Necrosis

Infected pancreatic necrosis (IPN) continues to be a challenging problem for the surgeon. We reviewed the experience on a hepatobiliary surgical service with patients who required operative intervention for IPN with emphasis on surgical approach, timing of surgery, and complications. Between 2002 and 2008, 21 patients underwent surgery for IPN. The initial surgical approach in these 21 patients included either direct pancreatic debridement (DPD, n = 13) or transgastric debridement using cyst-gastrostomy (CG, n = 8). Fifteen patients (71%) required only a single procedure, whereas three (14%) required two procedures and three (14%) required three procedures. The mean time from onset of pancreatitis to operation was 77 days. Patients requiring a single intervention had a longer interval from onset of pancreatitis to surgery compared with those requiring multiple interventions. When comparing CG and DPD groups, there was a longer interval from onset of pancreatitis to debridement, a lower chance of needing multiple debridements, and fewer pancreatic fistulae in the CG group. Overall survival was 95 per cent. Our results demonstrate that CG can be successfully used in select patients with IPN. Patients undergoing CG are less likely to require repeat surgical debridement and to develop pancreatic fistulae compared with patients undergoing DPD.

Surgical treatment of acute pancreatitis today

Az enyhe akut pancreatitis kezelése alapvetően konzervatív, míg súlyos esetekben a sebészi kezelésnek jelentős szerepe van. Módszer: A szerzők az utóbbi 10 évben megjelent, a műtét kérdéseit taglaló közlemények alapján elemzik a sebészi kezelés indikációit, időzítését és a műtét technikai kérdéseit. Eredmények/következtetések: A steril pancreasnecrosis csak ritkán, a szeptikus necrosis azonban műtéti indikációt képez, ha a konzervatív kezelés eredménytelen. A terápiarezisztens sokszervi elégtelenség, a súlyos hasi kompartmentszindróma és egyéb sebészi szövődmény, mint a vérzés, perforáció is műtéti beavatkozást tesz szükségessé. Pancreatitist okozó epekövesség talaján kialakult cholestasis esetén sürgős endoszkópos sphincterotomia és később cholecystectomia javasolt. Pancreasnecrosis esetén a műtét ideális időpontja a betegség kezdetétől számított 21. nap utánra tehető, mivel a „korai” műtétek szövődmény- és halálozási aránya magas. Fontos a gondos necrectomia, amelynek a retrocolicus és retroduodenalis terekre is ki kell terjednie. A nyitott has kezelésének több a szövődménye, ezért csak válogatott esetekben javasolják. A műtétet posztoperatív bursa omentalis lavage-zsal érdemes kiegészíteni. Orv. Hetil., 2010, 41, 1697–1701.

Pancreatite necro-hemorrágica: atualização e momento de operar

INTRODUÇÃO: A pancreatite necro-hemorrágica representa a variante mais grave do espectro de apresentações clínicas que podem compor o quadro da pancreatite aguda. Embora já conhecida há muitos séculos, inúmeras questões permanecem em aberto acerca dessa entidade e o número de trabalhos sobre o assunto publicados nos últimos anos tem sido muito expressivo. MÉTODO: Foi realizada ampla pesquisa na literatura, com especial atenção aos artigos publicados nos últimos três anos e indexados ao PubMed. Foram utilizados os seguintes descritores de forma cruzada: pancreatitis, surgical procedures; necrosis. A pesquisa inicial evidenciou cerca de 13.000 artigos, sendo avaliados os mais relevantes dos últimos três anos além de artigos mais antigos, considerados "clássicos" sobre o assunto e que, portanto, não poderiam deixar de ser citados. CONCLUSÃO: O tratamento da pancreatite aguda envolve um grande número de questões, dentre as quais as mais importantes estão relacionadas ao manejo da antibioticoterapia, tipo de dieta empregada e as questões relacionadas ao manejo da necrose infectada. Em especial, mudanças radicais foram implementadas nos últimos anos sobre todos esses tópicos, e uma atualização constante deve ser obrigatoriamente buscada pelos profissionais envolvidos no tratamento dessa doença.

Open pancreatic necrosectomy in the multidisciplinary management of postinflammatory necrosis

OBJECTIVE

To examine clinical outcome in a consecutive cohort of patients undergoing open necrosectomy for postinflammatory necrosis.

BACKGROUND INFORMATION

The last decade has witnessed major developments in the surgical management of pancreatic necrosis. Minimally invasive approaches have become established. However, there are limited data from contemporary open necrosectomy, in particular where multidisciplinary care and aggressive interventional radiology are used. This report provides data on outcome from open necrosectomy in a tertiary referral Hepatobiliary unit over the last decade.

METHODS

During the period January 1, 2000 to July 31, 2008, 1535 patients were admitted with a final discharge code of acute pancreatitis. Twenty-eight (1.8%) of all admissions underwent open surgical necrosectomy. Twenty-four (86%) were tertiary referral patients.

RESULTS

The median APACHE II score on admission was 10.5 (5-26). Median logistic organ dysfunction score on admission was 3 (0-10). Median LODS score after surgery was 2 (0-8). Twenty patients (71%) underwent radiologically guided drainage of collections before surgery. Thirty-day mortality occurred in 2 (7%), 4 further deaths occurred in patients after discharge from intensive care resulting in a total of 6 (22%) episode-related deaths.

CONCLUSIONS

Modern open necrosectomy can be performed without the procedure-related deterioration in organ dysfunction associated with major debridement. Multidisciplinary care with an emphasis on aggressive radiologic intervention before and after surgery results in acceptable outcomes in this cohort of critically ill patients. Newer laparoscopic techniques must demonstrate similar outcomes in the setting of stage-matched severity before wider acceptance.

Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach

OBJECTIVE

Comparison of minimal access retroperitoneal pancreatic necrosectomy (MARPN) versus open necrosectomy in the treatment of infected or nonresolving pancreatic necrosis.

SUMMARY OF BACKGROUND DATA

Infected pancreatic necrosis may lead to progressive organ failure and death. Minimal access techniques have been developed in an attempt to reduce the high mortality of open necrosectomy.

METHODS

This was a retrospective analysis on a prospective data base comprising 189 consecutive patients undergoing MARPN or open necrosectomy (August 1997 to September 2008). Outcome measures included total and postoperative ICU and hospital stays, organ dysfunction, complications and mortality using an intention to treat analysis.

RESULTS

Overall 137 patients underwent MARPN versus open necrosectomy in 52. Median (range) age of the patients was 57.5 (18-85) years; 118 (62%) were male. A total of 131 (69%) patients were tertiary referrals, with a median time to transfer from index hospital of 19 (2-76) days. Etiology was gallstones or alcohol in 129 cases (68%); 98 of 168 (58%) patients had a positive culture at the first procedure. Of the 137 patients, 34 (31%) had postoperative organ failure in the MARPN group, and 39 of 52 (56%) in the open group (P<0.0001); 59/137 (43%) versus 40/52 (77%), respectively, required postoperative ICU support (P<0.0001). Of the 137 patients 75 (55%) had complications in the MARPN group and 42 of 52 (81%) in the open group (P=0.001). There were 26 (19%) deaths in the MARPN group and 20 (38%) following open procedure (P=0.009). Age (P<0.0001), preoperative multiorgan failure (P<0.0001), and surgical procedure (MARPN, P=0.016) were independent predictors of mortality.

CONCLUSION

This study has shown significant benefits for a minimal access approach including fewer complications and deaths compared with open necrosectomy.

A step-up approach or open necrosectomy for necrotizing pancreatitis

BACKGROUND

Necrotizing pancreatitis with infected necrotic tissue is associated with a high rate of complications and death. Standard treatment is open necrosectomy. The outcome may be improved by a minimally invasive step-up approach.

METHODS

In this multicenter study, we randomly assigned 88 patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue to undergo primary open necrosectomy or a step-up approach to treatment. The step-up approach consisted of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy. The primary end point was a composite of major complications (new-onset multiple-organ failure or multiple systemic complications, perforation of a visceral organ or enterocutaneous fistula, or bleeding) or death.

RESULTS

The primary end point occurred in 31 of 45 patients (69%) assigned to open necrosectomy and in 17 of 43 patients (40%) assigned to the step-up approach (risk ratio with the step-up approach, 0.57; 95% confidence interval, 0.38 to 0.87; P=0.006). Of the patients assigned to the step-up approach, 35% were treated with percutaneous drainage only. New-onset multiple-organ failure occurred less often in patients assigned to the step-up approach than in those assigned to open necrosectomy (12% vs. 40%, P=0.002). The rate of death did not differ significantly between groups (19% vs. 16%, P=0.70). Patients assigned to the step-up approach had a lower rate of incisional hernias (7% vs. 24%, P=0.03) and new-onset diabetes (16% vs. 38%, P=0.02).

CONCLUSIONS

A minimally invasive step-up approach, as compared with open necrosectomy, reduced the rate of the composite end point of major complications or death among patients with necrotizing pancreatitis and infected necrotic tissue. (Current Controlled Trials number, ISRCTN13975868.)

Treatment strategy for acute pancreatitis

When a diagnosis of acute pancreatitis (AP) is made, fundamental medical treatment consisting of fasting, intravenous (IV) fluid replacement, and analgesics with a close monitoring of vital signs should be immediately started. In parallel with fundamental medical treatment, assessment of severity based on clinical signs, blood test, urinalysis and imaging tests should be performed to determine the way of treatment for each patient. A repeat evaluation of severity is important since the condition is unstable especially in the early stage of AP. At the time of initial diagnosis, the etiology should be investigated by means of blood test, urinalysis and diagnostic imaging. If a biliary pancreatitis accompanied with acute cholangitis or biliary stasis is diagnosed or suspected, an early endoscopic retrograde cholangiopancreatography with or without endoscopic sphincterotomy (ERCP/ES) is recommended in addition to the fundamental medical treatment. In mild cases, the fundamental medical treatment should be continued until clinical symptom is subsided with normal laboratory data. In cases with severe acute pancreatitis (SAP) referral should be considered to medical centers experienced in the treatment of SAP, and intensive care is recommended for preventing both organ failures and infectious complications. Hemodynamic stabilization with vigorous fluid resuscitation, respiratory support and antibiotics are the major parts of intensive care in the early period of SAP. Continuous hemodiafiltration (CHDF) and continuous regional arterial infusion (CRAI) of protease inhibitor and/or antibiotics may be effective to improve pathophysiology of AP especially in the early stage of the disease. In the late stage of AP, infectious complications are critical. If an infectious complication is suspected based on clinical signs, blood test and imaging, a fine needle aspiration (FNA) is recommended to establish a diagnosis. The accuracy of FNA is reported to be 89 ~ 100%. For patients with sterile pancreatitis, non-surgical treatment should be indicated. For patients with infected pancreatic necrosis, therapeutic intervention either by percutaneous, endoscopic, laparoscopic or surgical approach are indicated. The most preferred surgical intervention is necrosectomy, however, non-surgical treatment with antibiotics is still the treatment of choice if the general condition is stable. Necrosectomy should be performed as late as possible. For patients with pancreatic abscess, drainage is recommended.

Therapeutic intervention and surgery of acute pancreatitis

The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. Edematous pancreatitis accounts for 80-90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10-20% of acute pancreatitis and the mortality rate is reported to be 14-25%. The mortality rate is particularly high (34-40%) for infected pancreatic necrosis that is accompanied by bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148-154, 1993; Ogawa et al. in Research of the actual situations of acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry of Health, Labour, and Welfare. Heisei 12 Research Report, pp 17-33, 2001). On the other hand, the mortality rate is reported to be 0-11% for sterile pancreatic necrosis which is not accompanied by bacterial infection (Ogawa et al. 2001; Bradely and Allen in Am J Surg 161:19-24, 1991; Rattner et al. in Am J Surg 163:105-109, 1992). The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a variety of clinical characteristics. This article describes the guidelines for the surgical management and interventional therapy of acute pancreatitis by incorporating the latest evidence for the management of acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected pancreatic necrosis; (3) conservative treatment should be performed in sterile pancreatic necrosis; (4) infected pancreatic necrosis is an indication for interventional therapy. However, conservative treatment by antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a surgical procedure for infected necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess; (9) if the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts and (11) percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases.

Role of endosonography in drainage of fluid collections and other NOTES procedures

Endosonography (EUS) has become the accepted procedure for drainage of pancreatic fluid collections in the past decade. EUS was shown to be safe and effective and it has been the first-line therapy for uncomplicated pseudocysts. Where walled-off pancreatic necrosis was originally thought to be a contraindication for endoscopic treatment, multiple case series have now shown that these fluid collections also can be treated endoscopically with low morbidity and mortality. Analogous to the treatment of pancreatic fluid collections, others, such as abscesses in the lower and upper abdomen, have also been treated successfully, although there is limited literature in this regard, EUS appears to be a useful technique in natural orifice transluminal endoscopic surgery (NOTES) procedures as well.

Microbiological findings in secondary infection of severe acute pancreatitis: a retrospective clinical study

OBJECTIVES

The aim of our study was to evaluate the bacteriologic findings in secondary infection of severe acute pancreatitis (SAP) and the potential correlation with infection.

METHODS

Three hundred thirty-six patients with acute pancreatitis admitted to our department between January 1, 2000, and April 30, 2008, were recruited. All patients were treated with Chinese standard treatment. Of these 336 patients, 65 with infected necrosis were studied according to the clinical data.

RESULTS

Sixty-five (19.35%) of 336 patients had SAP with secondary infection; the time for secondary infection was diagnosed after a mean of 14 to 20 days. One hundred thirty-three strains were found in 65 patients with SAP with infection; culture-revealed organism infection included 85 gram-negative germs, 44 gram-positive germs, and 4 fungi. In the group without infection, 271 patients were managed conservatively, of which 16 patients (5.90%) died; in the other group, 61 (93.85%) of 65 patients were treated by operation and 15 patients (23.08%) died.

CONCLUSIONS

The predominant infections were gram-negative bacterium, gram-positive bacterium, and fungi concomitantly or consecutively. Most of the infected patients had polyinfection. There were many patients with hospital-acquired infection and opportunistic infection. Multiple factors affected the outcome.

A unifying concept: pancreatic ductal anatomy both predicts and determines the major complications resulting from pancreatitis

BACKGROUND

Precepts about acute pancreatitis, necrotizing pancreatitis, and pancreatic fluid collections or pseudocyst rarely include the impact of pancreatic ductal injuries on their natural course and outcomes. We previously examined and established a system to categorize ductal changes. We sought a unifying concept that may predict course and direct therapies in these complex patients.

STUDY DESIGN

We use our system categorizing ductal changes in pseudocyst of the pancreas and severe necrotizing pancreatitis (type I, normal duct; type II, duct stricture; type III, duct occlusion or "disconnected duct"; and type IV, chronic pancreatitis). From 1985 to 2006, a policy was implemented of routine imaging (cross-sectional, endoscopic retrograde cholangiopancreatography, or magnetic resonance cholangiopancreatography). Clinical outcomes were measured.

RESULTS

Among 563 patients with pseudocyst, 142 resolved spontaneously (87% of type I, 5% of type II, and no type III, and 3% of type IV). Percutaneous drainage was successful in 83% of type I, 49% of type II, and no type III or type IV. Among 174 patients with severe acute pancreatitis percutaneous drainage was successful in 64% of type I, 38% of type II, and no type III. Operative debridement was required in 39% of type I and 83% and 85% of types II and III, respectively. Persistent fistula after debridement occurred in 27%, 54%, and 85% of types I, II, and III ducts, respectively. Late complications correlated with duct injury.

CONCLUSIONS

Pancreatic ductal changes predict spontaneous resolution, success of nonoperative measures, and direct therapies in pseudocyst. Ductal changes also predict patients with necrotizing pancreatitis who are most likely to have immediate and delayed complications.

Cannabinoid receptor-1 blockade attenuates acute pancreatitis in obesity by an adiponectin mediated mechanism

BACKGROUND

Obesity is a risk factor for increased severity of acute pancreatitis. Adipocytes produce adiponectin, an anti-inflammatory molecule that is paradoxically decreased in the setting of obesity. We have shown that adiponectin concentration inversely mirrors the severity of pancreatitis in obese mice. Cannabinoid receptor CB-1 blockade increases circulating adiponectin concentration. We, therefore, hypothesize that blockade of CB-1 would increase adiponectin and attenuate pancreatitis severity.

METHODS

Forty lean (C57BL/6J) and 40 obese (Lep(Db)) mice were studied. Half of the mice in each strain received intraperitoneal injection of the CB-1 antagonist rimonabant (10 mg/kg daily for 7 days); the others received vehicle. Pancreatitis was induced by intraperitoneal injection of cerulein (50 microg/g hourly x 6). Pancreatitis severity was determined by histology. Pancreatic chemokine and proinflammatory cytokine concentrations were measured by ELISA.

RESULTS

Rimonabant treatment significantly increased circulating adiponectin concentration in obese mice (p < 0.03 vs. vehicle). After induction of pancreatitis, obese mice treated with rimonabant had significantly decreased histologic pancreatitis (p < 0.001), significantly lower pancreatic tissue levels of monocyte chemoattractant protein-1 (p = 0.03), tumor necrosis factor-alpha (p < 0.001), interleukin-6 (p < 0.001), and myeloperoxidase (p = 0.006) relative to vehicle-treated animals.

CONCLUSIONS

In obese mice, cannabinoid receptor CB-1 blockade with rimonabant attenuates the severity of acute pancreatitis by an adiponectin-mediated mechanism.

Prevention, detection, and management of infected necrosis in severe acute pancreatitis

The management of infected peripancreatic or pancreatic necrosis in patients with severe pancreatitis has changed considerably in recent years. This review discusses the recent literature on prevention, detection, and management of infected necrosis. Though antibiotics, probiotics, and enteral nutrition have been tried to prevent infected necrosis, only enteral nutrition has consistently proven to be effective. Antibiotics and probiotics have not shown a consistent beneficial effect on outcome. Enteral nutrition reduced infectious complications and mortality in severe pancreatitis, compared with parenteral nutrition. The detection of infection of pancreatic necrosis is important for clinical decision making. Fine-needle aspiration may be used to confirm suspected infection, but if its results will not change clinical decisions, it should be omitted, as it may even introduce infection. Minimally invasive surgical, radiologic, or endoscopic intervention is increasingly being applied. In the absence of level 1 evidence, local expertise dictates which type of intervention is applied.

Current status of minimally invasive necrosectomy for post-inflammatory pancreatic necrosis

OBJECTIVE

This paper reviews current knowledge on minimally invasive pancreatic necrosectomy.

BACKGROUND

Blunt (non-anatomical) debridement of necrotic tissue at laparotomy is the standard method of treatment of infected post-inflammatory pancreatic necrosis. Recognition that laparotomy may add to morbidity by increasing postoperative organ dysfunction has led to the development of alternative, minimally invasive methods for debridement. This study reports the status of minimally invasive necrosectomy by different approaches.

METHODS

Searches of MEDLINE and EMBASE for the period 1996-2008 were undertaken. Only studies with original data and information on outcome were included. This produced a final population of 28 studies reporting on 344 patients undergoing minimally invasive necrosectomy, with a median (range) number of patients per study of nine (1-53). Procedures were categorized as retroperitoneal, endoscopic or laparoscopic.

RESULTS

A total of 141 patients underwent retroperitoneal necrosectomy, of whom 58 (41%) had complications and 18 (13%) required laparotomy. There were 22 (16%) deaths. Overall, 157 patients underwent endoscopic necrosectomy; major complications were reported in 31 (20%) and death in seven (5%). Laparoscopic necrosectomy was carried out in 46 patients, of whom five (11%) required laparotomy and three (7%) died.

CONCLUSIONS

Minimally invasive necrosectomy is technically feasible and a body of evidence now suggests that acceptable outcomes can be achieved. There are no comparisons of results, either with open surgery or among different minimally invasive techniques.

The impact of hospital-acquired infection on outcome in acute pancreatitis

BACKGROUND & AIMS

Little is known regarding the impact of hospital-acquired infection (HAI) in acute pancreatitis (AP). We conducted a population-based assessment of the impact of HAI on outcome in AP.

METHODS

Patient data were obtained from the Cardinal Health Clinical Outcomes Research Database, a large population-based data set. Cases with principal diagnosis by International Classification of Diseases, ninth revision, clinical modification 577.0 (AP) between January 2004 and January 2005 were identified. These cases were linked with recently reported HAI data collected by the Pennsylvania Health Care Cost Containment Council. Identification of HAI was based on definitions set forth by the National Nosocomial Infection Surveillance System. We conducted a 5:1 multivariate propensity-matched cohort study to determine the independent contribution of HAI to in-hospital mortality, length of stay (LOS), and hospital charges.

RESULTS

From 177 participating hospitals, there were 11,046 AP cases identified. Eighty-two (0.7%) patients developed an HAI. Mortality in the overall AP population was 1.2% vs 11.4% among 405 matched non-HAI controls vs 28.4% among patients who developed HAI (chi(2) test, P < .0001). Fifteen percent of all deaths was associated with an HAI. Both average LOS and hospital charges were significantly increased among patients with HAI compared with matched non-HAI controls.

CONCLUSIONS

We determined that HAI had a major impact on mortality in AP. Patients who developed HAI also had significantly increased LOS and hospital charges. These differences were not explained by increased disease severity alone. Reducing HAI is an important step to improving outcome in AP.

Débridement and closed packing for the treatment of necrotizing pancreatitis

OBJECTIVE

To evaluate the results of débridement and closed packing for necrotizing pancreatitis and to determine the optimal timing of surgical intervention based on patient outcomes.

METHODS

Between February 1990 and November 1996, 64 consecutive patients with necrotizing pancreatitis were treated with necrosectomy followed by closed packing of the cavity with stuffed Penrose and closed suction drains. The mean APACHE II score immediately before surgery was 9, and 31% of the patients had organ failure. Patients were stratified with an outcome score based on death and major complications; this was correlated with the timing of surgical intervention. The data were then subjected to cut-point analysis by sequential group comparison.

RESULTS

Patients underwent surgery a median of 31 days after diagnosis. Fifty-six percent had infected necrosis. The mortality rate was 6.2% and was no different in infected or sterile necrosis. Eleven patients required a second surgical procedure and 13 required percutaneous drainage; a single surgical procedure sufficed in 69%. Enteric fistulae occurred in 16% of patients. The mean hospital stay after surgery was 41 days, and the interval until return to regular activities was 147 days. A significant negative correlation between duration of pancreatitis and outcome scores was found, and sequential group comparison demonstrated that the change point at which significantly better outcomes were encountered was day 27.

CONCLUSION

Débridement of pancreatic necrosis followed by closed packing and drainage is accomplished with a low mortality rate and reduced rates of complications and second surgical procedures. Although intervention is best deferred until the demarcation of necrosis is complete, delay beyond the fourth week confers no additional advantage.