Staying the Surgeon’s Hand: Role of Percutaneous Catheter Drainage in Acute Necrotising Pancreatitis
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Acute necrotising pancreatitis (NP) is associated with high morbidity and mortality. Patients with infected pancreatic necrosis (IPN) require some form of intervention in addition to medical management. Although there is no accepted consensus, it is generally agreed that the infected non-vital solid tissue needs to be removed in order to control the sepsis. The results of early surgery have not been encouraging, compared with cases where surgery was delayed or avoided. The placement of percutaneous catheter drains in such a situation helps to decrease the systemic inflammatory response and reverse organ dysfunction.
Aims and objectives
The aim of this study was to review retrospectively the results of percutaneous catheter drainage (PCD) in patients with acute NP requiring intervention.
Materials and methods
A retrospective study was conducted of patients presenting with acute NP from March 2012 to June 2015. Demographic, clinical, and perioperative information was retrieved from the medical records. The patients were initially managed in the intensive care unit (ICU) with goal-directed therapy and organ support where indicated. The patients with IPN and few with sterile pancreatic necrosis (SPN) who had persistent organ failure or whose clinical condition was deteriorating despite adequate medical support were subjected to some form of intervention. All the patients requiring PCD or surgical intervention were included in this study. These patients were divided into 3 groups based on the type of intervention: a) PCD only, b) PCD followed by surgical intervention, and (c) surgery alone. The outcome in these 3 groups was analyzed and the factors associated with failure of PCD were identified. In addition, the complications of SPN were investigated.
The records were reviewed of 46 patients diagnosed with acute NP, of which 23 required PCD or surgical intervention and were included in this study. The mean acute physiology and chronic health (APACHE II) score of these patients was 10.6 ± 3.45, while the mean bedside index of severity in acute pancreatitis (BISAP) score was 4.47 ± 0. 53. On contrast enhanced computed tomography (CECT) scan of the abdomen, 39% of the patients had >50% necrosis, with a mean CT severity index (CTSI) of 8.1 ± 1.9. Of the 21 patients treated initially with PCD, a step-up approach was applied in 8 patients, because of failure of PCD. The mean duration from admission to intervention was 19.5 days. A mean of 2.4 pigtail catheters were placed in each patient. Additional drains were placed in 3 patients. The duration of PCD ranged from 20 to 124 days. The mean ICU stay was 14.3 ± 3.2 days and the mean hospital stay was 35.8 ± 7.4 days. Post-intervention complications were recorded in 11 (47.8%) patients, of which 2 patients with PCD developed an external pancreatic fistula and 2 had bleeding. The mortality rate was 26% (6 patients).
PCD is a feasible and successful modality of treatment for acute NP requiring intervention. With the use of PCD, surgical necrosectomy may be completely avoided or delayed until the condition of the patient is stable enough to sustain surgery.
KeywordsNecrotising pancreatitis step-up approach percutaneous catheter drainage
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