PROSPECTIVE EVALUATION OF A TREATMENT PROTOCOL IN PATIENTS WITH SEVERE ACUTE NECROTIZING PANCREATITIS

Objective: Audit of the protocol for surgical treatment of patients wi th acute severe and necrotising pancreatitis (ANP). Design: Prospectiv e open study. Settings: University hospital, Finland. Patients: 33 pat ients treated for severe (Ranson score 3 or more) and necrotising (as judged on computed tomograms (CT)) pancreatitis between 1992-1993. Pro tocol: Indications for antibiotic treatment (n = 25 patients) were: fu lminant multiorgan disease; recurrent continual parallel increase in t emperature, white cell count (WCC) and C-reactive protein concentratio n; or the presence of bacteria on Gram stain of a percutaneous fine ne edle aspiration smear of necrosis. Three of the 25 responded to antibi otics. They and eight others with ANP but without these indications we re treated conservatively. Twenty-two patients underwent repeated necr osectomy by laparostomy. Main outcome measures: Diagnosis of pancreati c infection, morbidity and mortality. Results: Of the 22 patients oper ated on 17 had contaminated necrosis at operation, and this had been p redicted by the increasing inflammatory variable and the presence of b acteria in the Gram stain. Five patients operated on died (23%), four of the five having been operated on for fulminant multiorgan disease ( 80%). Recurrent sepsis developed in five patients, pancreatic fistulas in two, and there were no pseudocysts. Gastrointestinal fistulas deve loped in 12 patients, but not after we had changed the technique of wo und packing. All 11 patients treated conservatively survived. Conclusi on: A third of patients with ANP can be selected for safe non-operativ e treatment. Infected ANP can be treated by repeated necrosectomy by l aparostomy with low mortality (6%). Early fulminant multiorgan disease should not be treated with laparostomy.