JPN Guidelines for the management of acute pancreatitis: surgical management

Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2–3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of acute pancreatitis, excluding gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected pancreatic necrosis; (2) infected pancreatic necrosis accompanied by signs of sepsis is an indication for surgical intervention; (3) patients with sterile pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe clinical deterioration despite maximum intensive care; (4) early surgical intervention is not recommended for necrotizing pancreatitis; (5) necrosectomy is recommended as the surgical procedure for infected pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic abscess; (8) pancreatic abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9) pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10) pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.     

JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis

The basic principles of the initial management of acute pancreatitis are adequate monitoring of vital signs, fluid replacement, correction of any electrolyte imbalance, nutritional support, and the prevention of local and systemic complications. Patients with severe acute pancreatitis should be transferred to a medical facility where adequate monitoring and intensive medical care are available. Strict cardiovascular and respiratory monitoring is mandatory for maintaining the cardiopulmonary system in patients with severe acute pancreatitis. Maximum fluid replacement is needed to stabilize the cardiovascular system. Prophylactic antibiotic administration is recommended to prevent infectious complications in patients with necrotizing pancreatitis. Although the efficacy of the intravenous administration of protease inhibitors is still a matter of controversy, there is a consensus in Japan that a large dose of a synthetic protease inhibitor should be given to patients with severe acute pancreatitis in order to prevent organ failure and other complications. Enteral feeding is superior to parenteral nutrition when it comes to the nutritional support of patients with severe acute pancreatitis. The JPN Guidelines recommend, as optional measures, blood purification therapy and continuous regional arterial infusion of a protease inhibitor and antibiotics, depending on the patient's condition.     

Comparative Evaluation of the BISAP Score with CT Severity Index in Predicting the Severity of Acute Pancreatitis

Early diagnosis of severe acute pancreatitis (SAP) is important for the successful management of patients. Most scoring systems are complex or involve multiple parameters, which makes it difficult to ascertain the severity of acute pancreatitis at an early stage. Our study aims to evaluate the bedside index for severity in acute pancreatitis (BISAP) in predicting the severity of pancreatitis and mortality in a rural population, where financial constraints pose a major problem during treatment. We studied 55 patients of acute pancreatitis who presented to our institution between October 2014 and August 2016. The BISAP score was calculated within 24 h of admission. During the hospital stay, the CT severity index (CTSI) was calculated, and patients closely monitored to detect presence of organ failure or mortality. The accuracy of the BISAP and CTSI scores in predicting severity and mortality was determined by plotting receiver operating characteristic (ROC) curves, and calculating the area under curve (AUC). Sixteen (29%) patients developed persistent organ failure and were classified as severe acute pancreatitis (SAP), and four (7%) died. No patient with a BISAP score of 0 or 1 developed severe pancreatitis. The area under curve (AUC) for BISAP score in predicting severity and mortality was 0.902 and 0.958, respectively, better than that of CTSI. BISAP scores of 0 or 1 have a very high negative predictive value, and hence accurate for predicting mild disease. These patients can safely avoid a CT scan and the costs associated with it.     

30例重症胆源性胰腺炎延期手术探讨

目的　探讨重症胆源性胰腺炎 (GP)的手术时机。方法　对 1 995年 1月～ 1 999年 1 2月收治的 30例明确诊断为重症GP患者延期手术和病死率进行系统的回顾性分析。结果　 2例因梗阻性化脓性胆管炎早期急诊手术 ,术后 1例死于心衰。非手术治疗过程中 1例死于多器官功能衰竭。延期手术 2 7例 ,2例分别死于多器官功能衰竭和真菌性败血症。术后并发症 2例 ,分别是胰瘘和胰周残余脓肿。延期手术病死率和并发症发生率分别是 1 0 .0 %、6 .7%。结论　重症GP应首先行非手术治疗 ,待渡过急性期 ,一般于起病 3周后在同一住院期间延期手术 ,若非手术治疗过程中出现梗阻性化脓性胆管炎、胰腺坏死组织并发感染 ,应早期急诊手术。延期手术能保证较低的病死率     

Incidence and reversibility of organ failure in the course of sterile or infected necrotizing pancreatitis.

BACKGROUND: Multiple organ failure (MOF) and infected necrosis are both considered severe adverse events during the course of necrotizing pancreatitis. HYPOTHESIS: The incidence of MOF and its reversibility in patients with necrotizing pancreatitis are influenced by the presence or absence of infected necrosis. DESIGN: Case series. SETTING: Intensive care, university teaching hospital. PATIENTS: Forty-three patients with necrotizing pancreatitis and failure of at least 1 organ were prospectively included. MAIN OUTCOME MEASURES: Organ failure defined according to the Goris classification; MOF defined by the simultaneous occurrence of 3 organ failures and graded with an MOF score. Microbial status of necrosis was assessed by percutaneous or intraoperative sampling. Surgical drainage was performed in patients with infected necrosis, whereas sterile necrosis was managed conservatively. RESULTS: Infected necrosis occurred in 27 patients (63%). The mean (+/-SEM) number of organ failures was greater in cases of infection (3.6 +/- 1.1 vs 2.6 +/- 1.5; P =.02). Multiple organ failure occurred more frequently in cases of infected necrosis (23/27 vs 7/16; P<.01) and was responsible for an increased mortality in this subgroup (33% vs 6%; P =.1). The severity of MOF graded by the MOF score was related to the bacteriologic status of necrosis. CONCLUSIONS: The higher mortality commonly attributed to MOF in patients with infected necrosis appears to be due to a higher frequency and an increased severity of MOF. Conservative management in patients with severe necrotizing pancreatitis and sterile necrosis complicated by MOF is supported by the high reversibility rate of MOF and the low mortality rate observed in this series.     

Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis

BACKGROUND: All patients with organ dysfunction are currently classified as having severe acute pancreatitis. The aim of this study was to characterize the systemic inflammatory response syndrome (SIRS) and early organ dysfunction in patients with acute pancreatitis and the relationship with overall mortality. METHODS: Patients with predicted severe acute pancreatitis of less than 48 h duration had daily organ dysfunction scores and SIRS criteria calculated. These features were then correlated with outcome. RESULTS: Of 121 patients, 68 (56 per cent) did not develop organ dysfunction; only two of these patients died (mortality rate 3 per cent). Fifty-three (44 per cent) had early organ dysfunction, of whom 11 died (21 per cent). Organ dysfunction and persistent SIRS were both associated with an increased mortality rate, but on multivariate analysis only deteriorating organ dysfunction was an independent determinant of survival. CONCLUSION: Early organ dysfunction in acute pancreatitis usually resolves and in itself has no significant influence on mortality. In contrast, worsening organ dysfunction was associated with death in more than half of the patients (11 of 20); it is this group of patients who should be classified as having severe acute pancreatitis.     

Outcome of severe acute pancreatitis

BACKGROUND: The treatment of severe acute pancreatitis has been evolving from routine operative management to nonoperative care for patients without evidence of pancreatic infection. METHODS: Retrospective chart review of patients with severe acute pancreatitis at a single institution during a 9-year period. RESULTS: Sixty consecutive patients had severe pancreatitis. Forty-two had pancreatic necrosis on computed axial tomography (13 infected and 29 sterile). Patients with infected necrosis and 8 with sterile necrosis had operative debridement; the remaining patients were managed without operation (n = 39). The overall mortality was 15%. Mortality was directly related to the Acute Physiology and Chronic Health Examination II and Marshall organ failure scores (P <0.001). Patients who died had a greater incidence of nosocomial infection. CONCLUSIONS: Patients with infected pancreatic necrosis require early operative debridement, whereas those with sterile necrosis or severe pancreatitis without necrosis can usually be managed safely without surgery.     

中度急性胰腺炎临床特征分析

目的探讨中度急性胰腺炎的临床特征。方法回顾性分析2013年1月至12月,青海省交通医院普通外科收治的103例急性胰腺炎（acute pancreatitis,AP）患者临床资料,根据国际AP专题研讨会最新修订的诊断和分类标准（2012年,美国亚特兰大）诊断为轻度急性胰腺炎（mildacutepancreatitis,MAP）61例、中度急性胰腺炎（moderately severe acute pancreatitis,MSAP）25例、重度急性胰腺炎（severe acute pancreatitis,SAP）17例,对比三组患者一般资料、局部并发症发生此例、器官功能衰竭发生比例、入住ICU比例和天数、干预措施、住院天数、病死率。结果三组患者性别、年龄和病因学情况差异均无统计学意义,但MSAP组APACHEⅡ评分显著高于MAP组,同时低于SAP组（均P〈0．05）。MAP、MSAP和SAP三组出现局部并发症的比例分别为0、92．0％（23125）和76．5％（13／17）（P〈0．05）。MAP组无器官功能表竭发生,MSAP组5例出现一过性（〈48h）器官功能表竭,SAP组均出观特续性（〉48h）器官功能衰竭,SAP组器官功能衰竭比例显著高于MSAP组（P〈0．05）。MAP组无入住ICU病例,均无需介入、内镜或外科干预,无死亡病例。MSAP组入住ICU此例、ICU时间、住院时间和病死率显著低于SAP组（P〈0．05）。结论中度急性胰腺炎为有别于轻度和重度急性胰腺炎的独立类型,伴有局部并发症或一过性（48h内）器官功能表竭,但病死率较低,预后明显好于重度急性胰腺炎。     

Urinary trypsinogen activation peptide as a marker of severe acute pancreatitis

BACKGROUND: Trypsinogen activation peptide (TAP) may be an early marker of severe pancreatitis. Previous studies have included all patients with organ failure in the group with severe pancreatitis, although patients with transient organ failure may have a good prognosis. The aim of this study was to determine the value of urinary TAP estimation for prediction of severity of acute pancreatitis, and to validate use of several markers of prediction of severity against a new, stringent definition of severity. METHODS: Patients with acute pancreatitis were recruited within 24 h of onset of symptoms. Urine and blood samples were collected for 24 h, and Acute Physiology And Chronic Health Evaluation (APACHE) II (24 h), Ranson (48 h) and Glasgow (48 h) scores were calculated. Severe acute pancreatitis was defined by the presence of a local complication or the presence of organ failure for more than 48 h. RESULTS: Urinary TAP levels were significantly greater in patients with severe pancreatitis than in those with mild disease during the first 36 h of admission. The highest of three estimations of TAP in the first 24 h was as effective as APACHE II at 24 h in predicting severity. At 24 h after admission, urinary TAP was better than C-reactive protein (CRP) in predicting severity. The combination of TAP and CRP at 24 h allowed identification of high- and low-risk groups. The new definition of severity excluded 24 of 190 patients with transient organ failure; none of these patients died. CONCLUSION: Use of TAP improved early prediction of the severity of acute pancreatitis. Organ failure that resolves within 48 h does not signify a severe attack of acute pancreatitis.     

重症急性胰腺炎手术疗效的影响因素

目的 探讨重症急性胰腺炎病人手术疗效的影响因素.方法 观察分析从2005年1月至2007年7月于瑞金医院外科收治的SAP病人,对其中初次在该院手术的90例病人进行疗效影响因素的分析,并采用logistic回归,分别对FAP手术病人及非暴发性SAP手术病人进行关于手术效果的分析.结果 SAP手术病人存活率为81.11%,其中FAP手术病人存活率为75%.Logistic回归分析显示年龄、手术当日脏器功能障碍程度对所有SAP病人的手术疗效影响大.对于FAP病人行logistic回归分析显示在发病2周内行手术治疗比2周后手术疗效好;相反,非暴发性SAP病人则在发病2周后行手术治疗比2周内行手术疗效好.结论 手术指征和手术时机的合理选择是疗效提高的关键因素,FAP病人主要根据脏器功能障碍及腹内高压的发展趋势决定,最佳时机一般在发病两周内;而非暴发性SAP病人中,主要根据胰腺坏死感染及胰腺坏死相关的脏器功能障碍,最佳时机一般在发病两周后.     

Endoscopic sphincterotomy permits interval laparoscopic cholecystectomy in patients with moderately severe gallstone pancreatitis

Patients with moderately severe gallstone pancreatitis with substantial pancreatic and peripancreatic inflammation, but without organ failure, frequently have an open cholecystectomy to prevent recurrent pancreatitis. In these patients, prophylactic endoscopic retrograde cholangiography (ERC) with endoscopic sphincterotomy (ES) may prevent recurrent pancreatitis, permit laparoscopic cholecystectomy, and decrease risks. The medical records of all patients with pancreatitis undergoing cholecystectomy from 1999–2004 at the University of North Carolina Memorial Hospital were reviewed. Data regarding demographics, clinical course, etiology of pancreatitis, operative and endoscopic interventions, and outcome were extracted. Moderately severe gallstone-induced pancreatitis was defined as pancreatitis without organ failure but with extensive local inflammation. Thirty patients with moderately severe gallstone pancreatitis underwent ERC and ES and were discharged before cholecystectomy. Mean interval between ES and cholecystectomy was 102 ± 17 days. Cholecystectomy was performed laparoscopically in 27 (90%) patients, open in three (10%) patients, and converted to open in two (7%) patients, with a morbidity rate of 7% (two patients). No patient required drainage of a pseudocyst or developed recurrent pancreatitis. Interval complications resulted in hospital readmission in seven (23%) patients. In conclusion, recurrent biliary pancreatitis in patients with moderately severe gallstone pancreatitis is nil after ERC and ES. Hospital discharge of these patients permits interval laparoscopic cholecystectomy, but close follow-up is necessary in these potentially ill patients. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (poster presentation).     

早期器官功能障碍的监测在重症急性胰腺炎治疗方案选择中的意义

目的 探讨影响重症急性胰腺炎合并早期器官功能障碍治疗效果的因素和治疗方案的选择.方法 收集2007年7月至2008年12月连续收治的167例重症急性胰腺炎患者的临床资料,分析出现早期器官功能障碍患者的临床特点、病情演变趋势和治疗结果.分析正规非手术治疗、手术治疗及时机对治疗效果的影响.结果 167例患者中,68例(40.72%)出现了不同程度的早期器官功能障碍,其中单一器官功能障碍39例(57.4%),2个及2个以上器官功能障碍29例(42.6%).最常累及器官包括:心血管系统32例(47.1%)、肺脏24例(35.3%)和肾脏20例(29.4%).高龄(P<0.05)、APACHE Ⅱ评分高(P<0.05)是重症急性胰腺炎合并早期器官功能障碍预后不良的指标,早期手术干预有助于降低病死率.结论 重症急性胰腺炎合并早期器官功能障碍患者的病死率与患者的年龄、器官功能障碍严重程度相关.治疗方案应采用正规非手术治疗包括合理液体复苏、去除病因治疗,同时结合手术治疗.急性反应期的手术治疗应根据病情演变趋势、器官功能障碍程度加以判断,手术应在坏死感染发生之前进行.SOFA评分可作为手术指征判断的参考指标.     

Vascular endothelial growth factor increases in serum and protects against the organ injuries in severe acute pancreatitis

BACKGROUND: We have demonstrated that apoptosis was detected in liver and kidney cells in severe acute pancreatitis and that cellular injury because of apoptosis may be involved in the mechanism of multiple organ dysfunction syndrome. Vascular endothelial growth factor (VEGF) is a glycoprotein with potent angiogenic, mitogenic, and vascular permeability-enhancing activities specific for endothelial cells. It has been reported that VEGF is implicated in many diseases such as cancer and inflammation. METHODS: Serum VEGF concentrations were determined in patients with acute pancreatitis at the time of admission, and the relationships with severity, blood biochemical parameters on admission, organ dysfunction during the clinical course, and prognosis were analyzed. Moreover, to clarify the role of VEGF in acute pancreatitis, effects of VEGF were investigated in experimental severe acute pancreatitis. RESULTS: Serum VEGF levels were significantly elevated in patients with acute pancreatitis. Serum VEGF levels were not related to severity or prognosis. In male patients, among the various blood biochemical parameters, serum lactate dehydrogenase, and blood urea nitrogen levels were positively correlated with serum VEGF levels. Serum VEGF levels with organ dysfunction (liver and kidney) were higher than those without organ dysfunction. In rat experimental severe acute pancreatitis, serum VEGF levels were significantly elevated. Recombinant VEGF did not affect the lung water content, volume of ascitic fluid, hematocrit, or serum amylase, but improved the hepatic and renal dysfunctions. Apoptosis of liver and kidney was significantly inhibited by the administration of VEGF. CONCLUSIONS: These results suggest that VEGF is closely related to organ dysfunction in severe acute pancreatitis, and that VEGF may function as not a vascular permeability factor, but a protective factor via the anti-apoptotic effect against the organ injuries in this disease.     

探讨重症急性胰腺炎与器官功能衰竭之间的关系

目的：研究重症急性胰腺炎患者器官功能衰竭的发病率以及器官功能衰竭与胰腺坏死和感染坏死程度之间的关系。方法：将2003年3月-2011年6月被明确诊断为重症急性胰腺炎的患者纳入本研究。器官功能衰竭的诊断依据是Atlanta标准。感染坏死的诊断是基于标本培养阳性。依据CT扫描情况,胰腺坏死程度被分为〈30％,30～50％和〉50％。对持续器官功能衰竭患者的资料进行分析,探讨胰腺坏死和感染的程度与持续器官功能衰竭之间的关系。结果．128例重症急性胰稼炎患者,男99例,女29例,平均年龄（42．6±16．1）岁,522％（67／128）的患者有器官功能衰竭。在器官功能衰竭患者中,49—3％有1个器官功能衰竭,32．8％有2个器官功能衰竭和17.9％有多器官功能衰竭。肺衰竭是最常见的器官功能障碍（761％）。患者年龄的增加和越高的APACHEII评分是器官功能衰竭进展的重要危险因素（P〈0.05）。CT扫描显示：1个、2个和3个器官衰竭患者的胰8泉坏死超过50％的比例分别为48.5％、59-1％和83．3％,然而,在没有器官功能衰竭的患者中,只有27．9％的患者的胰腺坏死程度超过50％（P〈O.001）。没有发现感染坏死与器官功能衰竭之间存在相关性。总体死亡率为47．7％,衰竭的器官越多,死亡率越高（P〈0．os）。结论：52．2％的重症急性胰腺炎患者出现器官功能衰竭。器官功能衰竭的发生与年龄的增加、较高的APACHEII评分和胰腺坏死的程度显著相关,与感染坏死之间无显著相关性。     

Indications for the surgical management of pancreatic trauma: An update

Pancreatic trauma is rare compared to other abdominal solid organ injuries, accounting for 0.2%-0.3% of all trauma patients. Moreover, this type of injury may frequently be overlooked or not readily appreciated on initial clinical examinations and investigations. The organ injury scale determines the severity of the trauma. Nonetheless, there are conflicting recommendations for the best strategy in severe cases. Overall, conservative management of induced severe traumatic pancreatitis is adequate. Modern imaging modalities such as ultrasound scanning and computed tomography scanning can detect injuries in fewer than 60% of patients. However, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) have diagnostic accuracies approaching 90%-100%. Thus, management options include ERCP and stent placement or distal pancreatectomy in cases of complete gland transection and wide drainage only for damage control surgery, which can prevent mortality but increases the risk of morbidity. In the majority of cases, surgical intervention is not required and should be reserved for only severe grade III to grade V injuries.     

Blood purification methods for treatment of organ failure in patients with severe pancreatitis]

BACKGROUND: Recent years have shown a considerable progress in the management of severe pancreatitis (SP); however, the role of extracorporeal blood purification in the treatment of progressive multiple organ dysfunction syndrome (MODS) is not well assessed. THE AIM OF THIS STUDY: The retrospective assessment of the MODS treatment results after application of extracorporeal blood purification methods in SP patients. METHODS: 50 consecutive patients with acute pancreatitis were included in the study. Atlanta classification system was applied for stratification of patients with SP. MODS was defined according to the recommendations of the Consensus Conference of American College of Chest Physicians/Society of Critical Care Medicine in 1991, and MODS score was calculated. Involvement of the organ systems, ICU, hospital stays and main outcomes were analyzed. RESULTS: Totally, 45 patients met SP criteria. Necrotizing pancreatitis was found in 35 patients. In 19 cases the clinical course was complicated with peritonitis, in two with jaundice. Infection was present in four patients. MODS were observed in 34 patients, with average of 3.3-organ involvement. In total, 21 patients underwent surgery. Hemodialysis was necessary in 5 of the 21 patients with necrotizing pancreatitis. Hemofiltration was applied in 5, hemadsorption in 28 and plasmapheresis in 23 patients. The overall mortality in association with hemodialysis and hemofiltration reached 20 % in necrotizing pancreatitis patients. Hemadsorption was associated with 3.8 % mortality, and plasmapheresis with 25 % mortality rate in all SP patients. CONCLUSION: Combined derangement of the renal and hepatic function is highly associated with unfavorable outcome in patients with severe pancreatitis. Timely application of the extracorporeal blood purification methods may revert progression of MODS and can be successfully combined with surgery if it is needed in this category of patients.     

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重症急性胰腺炎治疗过程中面临的一个主要难题是在疾病的变化过程中预测其严重程度和潜在并发症。常见的评分标准包括Ranson、APACHEⅡ和序贯器官衰竭评分(SOFA)等。单一的预测指标除白细胞、血氧分压、血糖、血钙外,更有价值的有降钙素原、腹腔内压、BalthazarCT评分等。重症急性胰腺炎两个最重要标志是器官衰竭和胰腺坏死,预后评价应同时考虑器官衰竭和胰腺坏死因素,将形态学和生理学指标相结合,以提高预测的准确性。     

Acute necrotizing pancreatitis: treatment strategy according to the status of infection

OBJECTIVE: To determine benefits of conservative versus surgical treatment in patients with necrotizing pancreatitis. SUMMARY BACKGROUND DATA: 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 accompanied by organ failure is controversial. Recent clinical experience has provided evidence that conservative management of sterile pancreatic necrosis including early antibiotic administration seems promising. METHODS: A prospective single-center trial evaluated the role of nonsurgical management including early antibiotic treatment in patients with necrotizing pancreatitis. Pancreatic infection, if confirmed by fine-needle aspiration, was considered an indication for surgery, whereas patients without signs of pancreatic infection were treated without surgery. RESULTS: Between January 1994 and June 1999, 204 consecutive patients with acute pancreatitis were recruited. Eighty-six (42%) had necrotizing disease, of whom 57 (66%) had sterile and 29 (34%) infected necrosis. Patients with infected necrosis had more organ failures and a greater extent of necrosis compared with those with sterile necrosis. When early antibiotic treatment was used in all patients with necrotizing pancreatitis (imipenem/cilastatin), the characteristics of pancreatic infection changed to predominantly gram-positive and fungal infections. Fine-needle aspiration showed a sensitivity of 96% for detecting pancreatic infection. The death rate was 1.8% (1/56) in patients with sterile necrosis managed without surgery versus 24% (7/29) in patients with infected necrosis (P <.01). Two patients whose infected necrosis could not be diagnosed in a timely fashion died while receiving nonsurgical treatment. Thus, an intent-to-treat analysis (nonsurgical vs. surgical treatment) revealed a death rate of 5% (3/58) with conservative management versus 21% (6/28) with surgery. CONCLUSIONS: 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.     

Abdominal compartment syndrome in severe acute pancreatitis: an indication for a decompressing laparotomy?

BACKGROUND: The currently prevailing paradigm calls for non-operative management of severe acute pancreatitis for as long as there is no evidence of infection. Our purpose in presenting this anecdotal experience is to propose that there is a subset of patients who may need a laparotomy in the absence of infection in order to decompress a clinically significant abdominal compartment syndrome (ACS), which is associated with the acute pancreatitis. METHODS: We present our recent experience with three patients suffering from severe acute pancreatitis. The three developed intra-abdominal hypertension (IAHT) and clinical ACS, which necessitated abdominal decompression and a laparostomy. One patient survived. CONCLUSIONS: The notion that patients with severe acute pancreatitis may develop ACS, which necessitate emergency abdominal decompression, has been ignored by current surgical literature. Only increased awareness to the syndrome of IAHT-ACS in acute pancreatitis and transvesical measurement of intra-abdominal pressure will reveal its prevalence and significance.     

Prevention of severe change in acute pancreatitis: prediction and prevention.

Bacterial infection of pancreatic necrosis is the most frequent local complication of severe acute pancreatitis and is responsible for the majority of deaths in this disease. The development of systemic complications of severe acute pancreatitis such as septic multiple organ failure is closely related to infected necrosis. In this review, the factors predisposing to a severe course of acute pancreatitis are discussed as are clinical and laboratory markers which allow identification of patients at risk. Prevention of complications of acute pancreatitis is difficult. A variety of drugs including antiproteases and antiinflammatory agents have been shown to be of no benefit with regard to the reduction of severe complications. At present, based on the results of controlled trials, there is the widespread belief that prophylactic antibiotics are capable of reducing the incidence of infected pancreatic necrosis. New approaches for the prevention of systemic complications of severe acute pancreatitis are total enteral nutrition and local arterial infusion of antibiotics and antiproteases into the celiac trunk.