The clinical course of 47 patients with gallstone-associated acute pancreatitis who had surgery during the same admission has been reviewed. In 37 patients, when the signs and symptoms of pancreatitis settled on conservative management, biliary tract surgery was safely performed during that admission without mortality. The 10 patients whose clinical condition failed to settle prior to surgery had a complicated hospital stay and a 50 per cent mortality. A revised prognostic factor grading system has been outlined in which the age factor is removed and serum transaminase levels are considered of prognostic significance only if greater than 200 u/l within 48 h of admission. This revised system gives a more accurate assessment of the severity of individual attacks of gallstone-associated acute pancreatitis.
SUMMARY Review of all deaths from acute pancreatitis recorded at Glasgow Royal Infirmary between 1974 and 1984 identified 126 patients, 53 (42%) of whom had pancreatitis first diagnosed at necropsy. Aetiologies of the fatal attacks of pancreatitis included gall stones (30%), alcohol (15%), other identified aetiogical factors (17%), and was unknown (38%). Overall mortality fell from 14 9% in the early half of the study to 10 8% in the latter half although in the 73 patients in whom the diagnosis of acute pancreatitis was made during life, the mortality rate was unchanged throughout. Within the group of 73 patients diagnosed during life deaths from gall stone pancreatitis have fallen by almost 50% suggesting that improved treatment of this subgroup may have occurred. The findings of this study lend support to the concept of early, complete clearance of calculi from the biliary tree, either by an endoscopic or surgical approach.In a mainly retrospective review of acute pancreatitis from Glasgow Royal Infirmary over the decade to 1970, Imrie reported an overall mortality rate of 214% . 'A recent review from Bristol of the decade to 1979 found a mortality rate of 19 6%,2 a figure little changed from that of the preceding two decades.' In prospective therapeutic trials in Glasgow, mortality from acute pancreatitis fell from 11 5% in 1971-24 to 8-7% in 1974-7.' Such prospective trials, however, give an incomplete picture of the true incidence and mortality of acute pancreatitis by excluding patients who present atypically and those not diagnosed in life. The past decade has seen many changes in the management of acute pancreatitis and its complications but it is unclear whether these have influenced overall mortality. We have therefore undertaken a review of all deaths from acute pancreatitis at Glasgow Royal Infirmary between 1974 and 1984, during which time a series of prospective therapeutic trials were being conducted.
Twenty-four patients with postoperative external duodenal fistulas were managed in general surgical units over a six-year period. Management included aggressive nutritional support, localization and drainage of intraabdominal sepsis, and definitive surgical closure for those fistulas which did not close spontaneously. Spontaneous closure occurred in 92% of cases. All but one patient survived admission to hospital, and one patient died following readmission with intraabdominal sepsis resulting in a mortality of 8%. Provision of appropriate nutritional support and prompt control of sepsis has been associated with a low mortality rate and high rate of spontaneous fistula closure.
Bleeding as a complication of liver disease can occur in the absence ofrecognised haemostatic defects. It
Between January 1980 and June 1986, 21 patients required surgery for acute necrotizing pancreatitis. Four patients had been transferred from other hospitals; the remaining 17 patients had been treated from the outset at Glasgow Royal Infirmary, representing 3.7 per cent of the 456 patients treated for acute pancreatitis during this time. Necrosectomy was performed on 14 patients and 7 patients were treated by pancreatic resection, with 4 deaths in each group; thus 8 patients (38 per cent) died at a median time of 22 days from onset of their attack. Three of the four patients transferred to our care died, giving a mortality in our own patients of 29 per cent. Of the survivors, all but three had a prolonged and complicated hospital course. Our data confirm that acute necrotizing pancreatitis is still associated with a considerable mortality and morbidity. Early multi-organ failure, advanced age, underlying medical illness and the presence of infected necrosis were associated with a poor outcome. Necrosectomy delayed until the second or subsequent week appeared to be a suitable procedure for the majority of our patients, but shortcomings were apparent with the traditional methods of closed drainage of the pancreatic bed postoperatively. The many demands imposed by this small group of patients suggests that their management is best undertaken in centres in which there is special expertise and this should contribute to a further reduction in the mortality from this condition.
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