I. Nordback et al., PROSPECTIVE EVALUATION OF A TREATMENT PROTOCOL IN PATIENTS WITH SEVERE ACUTE NECROTIZING PANCREATITIS, The European journal of surgery, 163(5), 1997, pp. 357-364
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.