Outcome of Necrosectomy in Acute Pancreatitis: the Case for Continued Vigilance

Abstract

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.

Practice Guidelines in Acute Pancreatitis

“…One possible explanation is that there is considerable variation in the number of patients with severe necrotizing pancreatitis who are referred to individual hospitals for specialized care. In recent series, among the total number of patients with severe pancreatitis who were cared for in referral hospitals, the median percentage of referred patients was 63% (range 32-73%) (55,60,62,64,68,83,106,110,138,156,161,164). In some series (60,62,68), but not all (83,138), patients who were transferred were more seriously ill than those who were admitted directly to the reporting hospital.…”

“…This risk appears to correlate with prolonged use of antibiotic therapy (62)(63)(64). While the prevalence of fungal infection among patients with necrotizing pancreatitis in recent studies has been 9% (range 8-35%) (62,64,65,91,110,119,187), it remains unclear whether mortality is significantly higher when there is superimposed fungal infection. Some reports indicate a greater mortality (63,65,91,116), whereas others do not (62,64,115,119,187).…”

“…The types of surgery that have generally been recommended have included necrosectomy with closed continuous irrigation via indwelling catheters (47,55,89,104,110,112,119,156,164,169), necrosectomy and open packing (89,104,116,119,156,164,169), or necrosectomy with closed drainage without irrigation (89, 106). There have not been randomized prospective trials comparing these procedures.…”

Surgery for pancreatic necrosis: “Whom, when and what”

“…Increasing pre-operative organ dysfunction scores have been associated with an increase in mortality [25,26] and thus any delay in surgery following the diagnosis of infected necrosis is likely to be detrimental.…”

Minimally Invasive Management of Acute Necrotizing Pancreatitis

“…Minimally invasive necrosectomy techniques were developed to deal with the solid necrosis with the opportunity for less invasive treatment alternatives to the traditional primary surgical approach which results in significant deterioration and organ dysfunction [34]. The aim which these techniques have in common is the attempt to minimize the surgical stress and physiological insult in patients who are already critically ill [3,35,36].…”