ACUTE-PANCREATITIS - TREATMENT IN A SURGE RY WARD

The aim of this study was to examine the results of a policy in the tr eatment of acute pancreatitis (AP) : initial abstention, management in intensive care unit, surgery in cases of complication (infection and/ or failure of medical treatment). The modalities of the surgical treat ment were guided by CT scan findings : transperitoneal approach for di ffuse lesions, posterior approach for localized lesions. From 1986 to 1994, 57 patients (32 males, 25 females, mean age 59.2 years) were ref erred to our department for AP. Etiology was gallstones in 29 cases, a lcohol in 14 cases (Ranson <3), moderate in 27 cases (Ranson less than or equal to 5) and serious in 12 cases (Ranson greater than or equal to 6). According to the initial CT scan findings (56 cases), 9 patient s were classified grade A. 11 grade B, 13 grade C, 8 grade D ans 15 gr ade E. Thirty eight patients were managed conservatively (mean Ranson stage 3.3), while 19 patients underwent surgical treatment (mean Ranso n stage 4.6), in emergency for misdiagnosis (4 cases), or secondarily because of failure of medical management (15 cases). Surgery consisted in necrosectomy with active drainage in 13 cases and drainage alone i n 6 cases. Associated maneuvers included : cholecystectomy in 8 cases, cholecystostomy in 2 cases, jejunostomy in 7 cases and colic resectio n for necrosis in 3 cases. Two patients (5%) managed conservatively di ed (multiple organ failure and cardiac insufficiency) while 4 patients (21% : NS) who underwent surgery died (2 multiple organ failures, 1 s eptic shock, 1 myocardiac infarction). Mortality was correlated with t he Ranson score : 42% for serious AP, 3.7% for moderate AP and nil for mild AP (p <0.01). It was not correlated with CT scan grade, the onse t or the type of operation. These results allow us to conclude that su rgical treatment should be indicated only in cases of failure of conse rvative management, the best indication being uncontrolled sepsis. In this situation, active drainage provides good results since only one s epsis recurred among the 14 patients who underwent this procedure.