Strategy for treatment of acute necrotizing pancreatitis: Importance of continuous regional arterial infusion of protease inhibitor and antibiotics in the early phase

Abstract

A new strategy for the treatment of acute necrotizing pancreatitis (ANP) is reported. In this prospective study, all patients received intensive medical support. Surgery was performed in patients with infected pancreatic necrosis and/or sepsis. Continuous regional arterial infusion (CRAI) of the protease inhibitor, nafamostat mesilate, and the antibiotic imipenem was initiated in patients with ANP referred to our hospital within 7 days of the onset of the disease. Sixty patients with ANP were allocated to three groups: group I, no CRAI (n =16); group II, CRAI of nafamostat only (n=22); and group III, CRAI of nafamostat mesilate and imipenem (n=22). The mortality rate was 43.3% in group I, 13.6% in group II (P<0.05 vs group I), and 13.6% in group III (P<0.05 vs group I). The frequency of infected pancreatic necrosis was 50% in group I, 36.4% in group II, and nil in group III (P<0.01 vs group I and II). Combination of the protease inhibitor and the antibiotic infused intraarterially reduced the mortality rate and the frequency of infected pancreatic necrosis. However, 6 patients in the CRAI groups died of multiple organ failure (MOF), although the pancreatic necrosis was sterile. Massive retroperitoneal necrosis and bleeding was observed in these patients. CRAI is a potent mode of treatment in the early phase of necrotizing pancreatitis and most patients respond to this treatment. However, surgical intervention should be considered when the patient does not respond to CRAI and organ failure progresses, even though the pancreatic necrosis is sterile.