Primary Conservative Treatment Results in Mortality Comparable to Surgery in Patients With Infected Pancreatic Necrosis

doi:10.1016/j.cgh.2010.04.011

Clinical Gastroenterology and Hepatology

Volume 8, Issue 12, December 2010, Pages 1089-1094.e2

https://doi.org/10.1016/j.cgh.2010.04.011 Get rights and content

Background & Aims

The standard treatment for patients with infected pancreatic necrosis (IPN) is surgical necrosectomy. We compared the outcomes of surgical treatment versus primary conservative treatment (patients kept in intensive care unit and treated with antibiotics, organ support, intensive nutritional support, and, if required, percutaneous drainage) among patients with IPN.

Methods

We performed retrospective comparative (with prospectively acquired database) and prospective observational studies; data were collected from all consecutive patients with acute pancreatitis (n = 804), and those with IPN formed the study group. Patients with IPN were divided into 2 groups on the basis of diagnosis of IPN during 1997–2002 (group 1, n = 30) or 2003–2006 (group 2, n = 50). Eighteen patients in group 1 were treated by surgical necrosectomy, and 40 patients in group 2 were given primary conservative treatment; surgery was performed on patients if conservative treatment failed (n = 10). The primary outcome measure was mortality.

Results

The mortality was comparable in group 1 versus group 2 (43% vs 28%; P = .22). During a period of 10 years, the patients who received primary conservative treatment had significantly higher survival rates than those who received surgery (76.9% vs 46.4%; P = .005). In the prospective study during 2007–2008, the mortality from infected necrosis was 29.6% after primary conservative treatment, confirming the results of the comparative study.

Conclusions

In treating patients with IPN, a primary conservative strategy resulted in mortality that was comparable with that after surgery, and 76% of the patients were able to avoid surgery; 54.5% of IPN patients were successfully managed with the primary conservative strategy.

Section snippets

Methods

The study design was a comparative study. The setting was a tertiary care academic center.

Results

A total of 804 consecutive patients were included in the study during the 12-year period. Of them, 683 patients with acute pancreatitis were included in the comparative study from January 1997 to December 2006 (Figure 1).

Discussion

IPN accounts for most of the mortality in patients with AP.1, 4 The standard and accepted treatment for patients with IPN has been surgical necrosectomy.6, 7 There has been no randomized comparative trial between conservative and surgical therapy in patients with IPN, primarily because conservative management was never considered a viable treatment option.

The present study, which compares conservative and surgical therapies in patients with IPN, has shown that a management strategy of primary

Acknowledgments

The authors thank Dr V Sreeniwas, Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India, for his great help in this study.

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Epidemiology and risk factors for mortality in critically ill patients with pancreatic infection
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The AbSeS-classification defines specific phenotypes of patients with intra-abdominal infection based on the (1) setting of infection onset (community-acquired, early onset, or late-onset hospital-acquired), (2) presence or absence of either localized or diffuse peritonitis, and (3) severity of disease expression (infection, sepsis, or septic shock). This classification system demonstrated reliable risk stratification in intensive care unit (ICU) patients with intra-abdominal infection. This study aimed to describe the epidemiology of ICU patients with pancreatic infection and assess the relationship between the components of the AbSeS-classification and mortality.
This was a secondary analysis of an international observational study (“AbSeS”) investigating ICU patients with intra-abdominal infection. Only patients with pancreatic infection were included in this analysis (n=165). Mortality was defined as ICU mortality within 28 days of observation for patients discharged earlier from the ICU. Relationships with mortality were assessed using logistic regression analysis and reported as odds ratio (OR) and 95% confidence interval (CI).
The overall mortality was 35.2% (n=58). The independent risk factors for mortality included older age (OR=1.03, 95% CI: 1.0 to 1.1 P=0.023), localized peritonitis (OR=4.4, 95% CI: 1.4 to 13.9 P=0.011), and persistent signs of inflammation at day 7 (OR=9.5, 95% CI: 3.8 to 23.9, P<0.001) or after the implementation of additional source control interventions within the first week (OR=4.0, 95% CI: 1.3 to 12.2, P=0.013). Gram-negative bacteria were most frequently isolated (n=58, 49.2%) without clinically relevant differences in microbial etiology between survivors and non-survivors.
In pancreatic infection, a challenging source/damage control and ongoing pancreatic inflammation appear to be the strongest contributors to an unfavorable short-term outcome. In this limited series, essentials of the AbSeS-classification, such as the setting of infection onset, diffuse peritonitis, and severity of disease expression, were not associated with an increased mortality risk.
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La pancreatitis aguda continúa siendo una de las patologías más relevantes en los servicios de aparato digestivo, destacando la litiasis y el alcohol como las causas principales. Presenta unos criterios diagnósticos bien establecidos y unas indicaciones específicas para la realización de pruebas de imagen, considerando de gran utilidad la ecografía abdominal en el estudio etiológico y la tomografía computarizada abdominal para la estratificación del riesgo y estudio de complicaciones locales. Una fluidoterapia basada en metas, el uso precoz de la nutrición por vía oral y una adecuada analgesia constituyen los pilares básicos del manejo inicial. La antibioterapia está indicada en casos de necrosis infectada o infecciones extrapancreáticas pero no ha demostrado beneficio como profilaxis en pancreatitis aguda necrotizante. En la última década se han desarrollado abordajes mínimamente invasivos que han cambiado radicalmente el tratamiento de las necrosis encapsuladas mejorando la tasa de complicaciones, estancia hospitalaria y calidad de vida de los pacientes.
Acute pancreatitis is nowadays one of the most common diseases among gastroenterology disorders, being gallstones and alcohol the main etiologies. Diagnostic criteria and indications of different imaging techniques are well defined, so that abdominal ultrasound is useful for etiological diagnosis whereas computarized tomography is better for risk stratification and local complications assessment. Goal directed fludtherapy, early starting of oral feeding and pain management are the mainstay of early treatment in acute pancreatitis. Antibiotics are useful when infected necrosis or extra pancreatic infections are documented or suspected but no as prophylaxis in sterile necrotizing pancreatitis. Minimally invasive approaches have emerged in the last decade for walled off necrosis management, improving complication rates, quality of life and length of hospital stay when compared with open surgery.
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Out of 363 patients hospitalized during the study-period, 33(9%) patients developed hemorrhage. Median time from onset of AP to hemorrhage was 59(45–68) days. The cause of hemorrhage was arterial in 19(57.5%) patients and unlocalized in 14(42.5%) patients. Hemorrhage was managed by conservative approach in 7 (21.2%), radiographic angioembolisation in 16 (48.5%), radiographic angioembolisation followed by surgery in 3 (9.1%), and surgery in 7 (21.2%) patients. Persistent organ failure [aHR 2.3 (1.1–5.1), p = 0.03], use of large bore (>20 Fr) catheter for initial drainage [aHR 3.9 (1.7–9.1), p = 0.001] and extensive (>50%) necrosis [aHR 3.1 (1.4–6.9), p = 0.005] were significant risk factors for hemorrhage. Hemorrhage was an independent predictor of mortality [aHR 2.0 (1.2–3.4), p = 0.008] in addition to persistent organ failure (aHR 12.1 (5.7–25.8), p < 0.001). In-hospital mortality in patients with hemorrhage was 22/33 (66.7%) vs. 81/330 (25%) in no hemorrhage group [p <0.001].
Pancreatic hemorrhage occurs later in the course of acute pancreatitis in relatively sicker group of patients with organ failure and extensive necrosis, and is independently associated with a higher risk of in-hospital mortality.
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Citation Excerpt :
An intervention is said to be primary if it is the first intervention performed to access WON and secondary if preceded by another intervention.7 Selected patients with infected necrosis who are minimally symptomatic and clinically stable can be managed using antibiotics alone, with or without selective percutaneous drainage.62–65 A meta-analysis involving 324 patients from 8 studies showed that primary nonoperative management of infected necrosis without necrosectomy was successful in 64% of patients and was associated with lower mortality, obviating the need for open necrosectomy.63
The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.

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: Conflicts of interest The authors disclose no conflicts.

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Original article—liver, pancreas, and biliary tractPrimary Conservative Treatment Results in Mortality Comparable to Surgery in Patients With Infected Pancreatic Necrosis

Background & Aims

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Acknowledgments

Clin Gastroenterol Hepatol

Pancreatology

Am J Gastroenterol

Pancreatology

Surgery

Am J Surg

Gastrointest Endosc

Clinical practice: acute pancreatitis

N Engl J Med

A clinically based classification system for acute pancreatitis: summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992

Arch Surg

Bacterial infection and extent of necrosis are determinants of organ failure in patients with acute necrotizing pancreatitis

Br J Surg

Management of acute pancreatitis: from surgery to interventional intensive care

Gut

UK guidelines for the management of acute pancreatitis

Gut

Original article—liver, pancreas, and biliary tract
Primary Conservative Treatment Results in Mortality Comparable to Surgery in Patients With Infected Pancreatic Necrosis