Modern Phase-Specific Management of Acute Pancreatitis

Abstract

The management of acute necrotizing pancreatitis has changed significantly over the past years. In contrast to the early surgical intervention of the past, there is now a strong tendency towards a more conservative approach. Initially, severe acute pancreatitis is characterized by the systemic inflammatory response syndrome. Early management is non-surgically and solely supportive. A specific treatment still does not exist. In cases of necrotizing disease, prophylactic antibiotics should be applied to reduce late septic complications. Today, more patients survive the first phase of severe pancreatitis due to improvements of intensive care medicine, thus increasing the risk of later sepsis. Pancreatic infection is the major risk factor with regard to morbidity and mortality in the second phase of severe acute pancreatitis. Whereas early surgery and surgery for sterile necrosis can only be recommended in selected cases, pancreatic infection is a well-accepted indication for surgical treatment in the second phase of the disease. Surgery should ideally be postponed until 4 weeks after the onset of symptoms, as necrosis is well demarcated at that time. Three surgical techniques can be performed with comparable results regarding mortality: necrosectomy combined with the (1) open packing technique, (2) planned staged relaparotomies with repeated lavage, or (3) closed continuous lavage of the retroperitoneum. However, the latter method seems to be associated with the lowest morbidity compared to the other approaches.

Outcome of patients with acute, necrotizing pancreatitis requiring drainage-does drainage size matter?

“…Six surviving patients (8%) required surgical necrosectomy because percutaneous therapy failed in controlling sepsis. The mortality rate in this study was 34% which is within the expected range of 20%-40% [10][11][12] reported in the literature. Considering that the study population represented a seriously ill subset of patients as evidenced by high clinical and radiological scores, a mortality rate of 34% is an acceptable outcome.…”

“…The standard treatment has traditionally been surgery [5,6] . By using modern surgical techniques like open packing, repeated laparatomies, closed packing or closed continuous lavage mortality rates could be decreased to 20%-40% [7][8][9][10][11][12] . However, these techniques are associated with a considerable surgical trauma which often causes escalation of multiorgan failure and sepsis [7,13] .…”

Predicting Factors of Pancreatic Infection in Acute Necrotizing Pancreatitis: A Report of 119 Cases

“…Autopsy results confirm that pulmonary complications were among the most common causes of death during the first week of disease progression [31] . Hypoxia is associated with multiple organ failure and high mortality [32][33][34] .…”

Severe acute pancreatitis: Case-oriented discussion of interdisciplinary management

“…In the management of documented pancreatic infection surgical removal of necrotic tissue is of paramount importance and generally accepted, since conservative treatment alone was associated in some studies with an unacceptably high mortality of up to 100% [4,75] . The occurrence of infection must be suspected whenever the clinical situation in a patient with necrotic pancreatitis is deteriorating with increasing signs of infl ammation (fever, CRP 1 180 mg/ml, leukocytosis), increasing pain, hemodynamic instability and progressive multi-organ dysfunction syndrome.…”