The Role of Surgery in the Management of Acute Pancreatitis

The clinical course of an episode of acute pancreatitis varies from a mild, transitory form to a severe necrotizing form characterized by multisystem organ failure and mortality in 20% to 40% of cases. Mild pancreatitis does not need specialized treatment, and surgery is necessary only to treat underlying mechanical factors such as gallstones or tumours at the papilla of Vater. On the other hand, patients with severe necrotizing pancreatitis need to be identified as early as possible after the onset of symptoms to start intensive care treatment. In this subgroup of patients, approximately 15% to 20% of all patients with acute pancreatitis, stratification according to infection status is crucial. Patients with infected necrosis must undergo surgical intervention, which consists of an organpreserving necrosectomy followed by postoperative lavage and/or drainage to evacuate necrotic debris, which appears during the further course of the condition. Primary intensive care treatment, including antibiotic treatment, delays the need for surgery in most patients until the third or fourth week after the onset of symptoms. At that time, necrosectomy is technically easier to perform and the bleeding risk is reduced, compared with necrosectomy earlier in the disease course. In patients with sterile necrosis, the available data strongly support a conservative approach (ie, intensive care unit treatment). Surgery is rarely necessary in these patients.

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Operative vs Non-Operative Management in Sterile Necrotizing Pancreatitis

HPB Surgery ◽

10.1155/1997/30279 ◽

1997 ◽

Vol 10 (3) ◽

pp. 188-191 ◽

Cited By ~ 6

Author(s):

Edward L. Bradley

Keyword(s):

Intensive Care ◽

Pancreatic Necrosis ◽

Necrotizing Pancreatitis ◽

Operative Management ◽

Needle Aspiration ◽

Apache Ii ◽

Intensive Care Treatment ◽

Intensive Care Therapy ◽

Care Treatment ◽

Organ Complications

Background: The clinical management of sterile pancreatic necrosis is still a matter of debate. In this study we analyzed the clinical course and outcome of patients with sterile necrotizing pancreatitis treated surgically versus nonsurgically.Study Design: Between May 1982 and December 1993, 249 patients with necrotizing pancreatitis (NP) entered this study, of which 172 (69 percent) had intraoperatively or fine needle aspiration-proven sterile NP. One hundred seven of 172 patients underwent surgery (S group) with necrosectomy and continuous postoperative closed lavage and 65 of 172 were treated by nonsurgical means (NS group).Results: Median Ranson and admission APACHE II scores were 4.7 (range, 1 to 10) and 11 (range, 1 to 29) in the S group, significantly higher than those in the NS group with 3.0 (range, 0 to 6) (p=0.022) and 8 (range, 1 to 23) (p=0.036). After 48 hours of intensive care treatment, APACHE II scores persisted at 10.5 (range, 1 to 29) in the S group and decreased to 6 (range, 0 to 15) (p=0.013) in the NS patients. Median Creactive protein (CRP) levels on admission were 179 mg/L and 68.5 mg/L (p=0.023), respectively. Within 72 hours, 61 (94 percent) of 65 NS-managed patients responded to intensive care therapy, whereas organ complications persisted or increased and thus led to surgery in the S group. Mortality rates were 13.1 percent in the surgically treated patients and 6.2 percent in the nonsurgically treated patients (p=NS).Conclusions: Most patients with limited and sterile pancreatic necrosis respond to intensive care treatment. Indication for surgery in sterile NP should be based on persisting or advancing organ complications despite intensive care therapy. APACHE II scores and adraission CRP levels represent a helpful tool in decision making for surgical or nonsurgical management of NP.

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Intensive care treatment with recombinant human thrombomodulin administration in a patient with severe acute pancreatitis and disseminated intravascular coagulation

Journal of the Japanese Society of Intensive Care Medicine ◽

10.3918/jsicm.22.443 ◽

2015 ◽

Vol 22 (5) ◽

pp. 443-444

Author(s):

Takenori Makino ◽

Norihisa Yasuda ◽

Ryo Shitomi ◽

Yojiro Ogiwara ◽

Yoshifumi Ohchi ◽

...

Keyword(s):

Acute Pancreatitis ◽

Intensive Care ◽

Severe Acute Pancreatitis ◽

Disseminated Intravascular Coagulation ◽

Intensive Care Treatment ◽

Intravascular Coagulation ◽

Care Treatment

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A case report of severe acute pancreatitis with infected necrosis and concomitant Coronavirus Disease‑19 (COVID‑19): a nosocomial infection or delayed respiratory manifestation of viral disease?

General Surgery ◽

10.30978/gs-2021-1-42 ◽

2021 ◽

Author(s):

Y. Susak ◽

O. Tkachenko ◽

O. Lobanova ◽

L. Skivka

Keyword(s):

Intensive Care Unit ◽

Acute Pancreatitis ◽

Intensive Care ◽

Case Report ◽

Hospital Stay ◽

Necrotizing Pancreatitis ◽

Treatment Protocol ◽

Symptom Improvement ◽

Infected Necrosis ◽

Pancreatic Debridement

The association between COVID‑19 and acute pancreatitis (AP) has been extensively analyzed in recent research and review papers worldwide. It should be noted that most studies have focused on AP as a COVID‑19 complication and/or an extra‑pulmonary manifestation of the disease, although the investigation reports on the cases of prior pancreatitis and subsequent COVID‑19 infection are limited. The aim of this case report is to describe the treatment protocol and clinical outcome of a patient with acute necrotizing pancreatitis who developed nosocomial COVID‑19.. Case presentation. The data were collected from patient S., a 42‑year‑old male admitted with AP to the intensive care unit of Kyiv City Clinical Emergency Hospital, in October 2020. This study was reviewed and approved by the local Ethics Committee (Protocol No 25‑15‑60). The patient signed written informed consent to participate in the study, after having been informed of all relevant aspects that could influence his decision. The patient, primarily diagnosed with AP, was admitted to the hospital without a PCR test for detecting SARS‑CoV‑2. 21 days after his admission to the hospital, the patient developed COVID‑19. AP progression to severe AP with infected necrosis, the development of systemic inflammatory response syndrome and multiple organ failure necessitated operative pancreatic debridement, which was postponed due to severe acute respiratory failure. Operative pancreatic debridement was performed on the 45th day of hospital stay after the resolution of COVID‑19‑associated pneumonia. The postoperative period was typical for the disease severity and the extent of the surgery, and was complicated by external pancreatic and colonic fistulas. The length of hospital stay for this patient was 115 days which included 20 days of treatment and monitoring in the intensive care unit due to pneumonia. He was discharged after clinical symptom improvement. Conclusions. It is imperative to screen patients presenting with AP for SARS‑CoV‑2 in order to avoid misdiagnosis and inappropriate treatment strategy. Further detailed investigation of mechanisms of pancreatic injury in patients with SARS‑CoV‑2 is necessary.

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Prolonged intensive care treatment of octogenarians after cardiac surgery: Is the economic burden justified?

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0031-1297792 ◽

2012 ◽

Vol 60 (S 01) ◽

Author(s):

H Deschka ◽

L Vöhringer ◽

J Neufeld ◽

G Wimmer-Greinecker

Keyword(s):

Cardiac Surgery ◽

Intensive Care ◽

Economic Burden ◽

Intensive Care Treatment ◽

Care Treatment

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The presence of liver cirrhosis is a strong negative predictor of survival for patients admitted to the intensive care unit – Cirrhosis in intensive care patients

Zeitschrift für Gastroenterologie ◽

10.1055/a-1401-2387 ◽

2021 ◽

Author(s):

Jörg Bojunga ◽

Mireen Friedrich-Rust ◽

Alica Kubesch ◽

Kai Henrik Peiffer ◽

Hannes Abramowski ◽

...

Keyword(s):

Intensive Care Unit ◽

Liver Cirrhosis ◽

Intensive Care ◽

Hospital Mortality ◽

Intensive Care Treatment ◽

Matched Cohort ◽

Care Treatment ◽

Cirrhotic Patients ◽

The Impact ◽

Cirrhotic Group

Abstract Background and Aims Liver cirrhosis is a systemic disease that substantially impacts the body’s physiology, especially in advanced stages. Accordingly, the outcome of patients with cirrhosis requiring intensive care treatment is poor. We aimed to analyze the impact of cirrhosis on mortality of intensive care unit (ICU) patients compared to other frequent chronic diseases and conditions. Methods In this retrospective study, patients admitted over three years to the ICU of the Department of Medicine of the University Hospital Frankfurt were included. Patients were matched for age, gender, pre-existing conditions, simplified acute physiology score (SAPS II), and therapeutic intervention scoring system (TISS). Results A total of 567 patients admitted to the ICU were included in the study; 99 (17.5 %) patients had liver cirrhosis. A total of 129 patients were included in the matched cohort for the sensitivity analysis. In-hospital mortality was higher in cirrhotic patients than non-cirrhotic patients (p < 0.0001) in the entire and matched cohort. Liver cirrhosis remained one of the strongest independent predictors of in-hospital mortality (entire cohort p = 0.001; matched cohort p = 0.03) along with dialysis and need for transfusion in the multivariate logistic regression analysis. Furthermore, in the cirrhotic group, the need for kidney replacement therapy (p < 0.001) and blood transfusion (p < 0.001) was significantly higher than in the non-cirrhotic group. Conclusions In the presented study, liver cirrhosis was one of the strongest predictors of in-hospital mortality in patients needing intensive care treatment along with dialysis and the need for ventilation. Therefore, concerted efforts are needed to improve cirrhotic patients’ outcomes, prevent disease progression, and avoid complications with the need for ICU treatment in the early stages of the disease.

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