Timing of Surgical Intervention in Necrotizing Pancreatitis

Abstract

To determine the effect of timing of surgical intervention for necrotizing pancreatitis. Design: Retrospective study of 53 patients and a systematic review. Setting: A tertiary referral center. Main Outcome Measure: Mortality. Results: Median timing of the intervention was 28 days. Eighty-three percent of patients had infected necrosis and 55% had preoperative organ failure. The mortality rate was 36%. Sixteen patients were operated on within 14 days of initial admission, 11 patients from day 15 to 29, and 26 patients on day 30 or later. This latter group received preoperative antibiotics for a longer period (PϽ.001), and Candida species and antibiotic-resistant organisms were more often cultured from the pancreatic or peripancreatic necrosis in these patients (P=.02). The 30-day group also had the lowest mortality (8% vs 75% in the 1 to 14-days group and 45% in the 15 to 29days group, PϽ.001); this difference persisted when outcome was stratified for preoperative organ failure. During the second half of the study, necrosectomy was further postponed (43 vs 20 days, P = .06) and mortality decreased (22% vs 47%, P=.09). We also reviewed 11 studies with a total of 1136 patients. Median surgical patient volume was 8.3 patients per year (range, 5.3-15.6), median timing of surgical intervention was 26 days (range, 3-31), and median mortality was 25% (range, 6%-56%). We observed a significant correlation between timing of intervention and mortality (R=−0.603; 95% confidence interval, −2.10 to −0.02; P =.05). Conclusion: Postponing necrosectomy until 30 days after initial hospital admission is associated with decreased mortality, prolonged use of antibiotics, and increased incidence of Candida species and antibioticresistant organisms.

Video-Assisted Retroperitoneal Debridement (VARD) of Infected Necrotizing Pancreatitis: An Update

“…Whereas necrosectomy was once performed very early after the onset of disease, intervention is now increasingly delayed to approximately three to four weeks after onset of disease resulting in lower complications and mortality rates [23][24][25][26]. In order to postpone intervention, patients with signs of infected necrosis are initially treated with broad-spectrum antibiotics and maximal support of organ systems.…”

Splenic Rupture by Tubular Drain in a Patient with Necrotizing Pancreatitis

“…Moreover, postpone the intervention allows the separations between necrosis and viable tissue, in a way that if the necrosectomy is executed, the chance of removal of the viable tissue is minimized, allowing a better endocrine and exocrine prognostic [3,9,15,16]. In most cases, the sterile acute necrosis doesn't require early intervention (only if there are signs of sepsis).…”

Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study

“…Consensus regarding the timing of intervention is lacking as shown by an almost equal division between respondents awaiting the full effect of antibiotics or those immediately proceeding to intervention in infected necrosis. This discrepancy in timing of intervention was most apparent in the early case vignettes, before the stage of walled-off necrosis (day [7][8][9][10][11][12][13][14][15][16][17][18][19][20]. This implies that some pancreatologists feel that a non-invasive approach with antibiotics alone is an effective treatment for infected necrosis.…”