Abstract
One hundred and two patients with acute necrotizing pancreatitis were treated in accordance with a combined regimen of necrosectomy, open drainage by laparostomies, and repeated re-explorations. The severity of pancreatitis was assessed by the APACHE II score (median 15 on admission). Eighty-seven (85%) patients were classified as having infected pancreatic necrosis and only 15 (15%) as having pancreatic necrosis. Overall, 36 (35%) patients died, most of multiple organ failure. Survival was significantly impaired by bacterial contamination of pancreatic necrosis (p=0.008),bacteremia (p=0.0001)and infected bronchial secretions (p=0.05).The mortality rate was reduced from 53% to 28% by changing the regimen of re-explorations from on demand to regular 48 hour intervals. Despite the fact that open packing was associated with a high frequency of gastrointestinal fistulas (30%), this concept seems to be a successful and recommendable approach in the therapy of pancreatic and infected pancreatic necrosis.
Résumé
Cent deux patients ayant une pancréatite nécrosante ont été traités par nécrosectomie, suivie de drainage ouvert par laparotomie avec réexploration répétée. La sévérité de la pancréatite a été évaluée par système APACHE II (médiane=15 à l'admission). Quatre vingt patients (85%) ont été classés comme ayant une nécrose pancréatique infectée et 15 seulement (15%) comme ayant une nécrose pancréatique. Trente six patients (35%) sont morts, la plupart de défaillance polyviscérale. La survie a été influencée de façon significative lorsque la nécrose était contaminée (p=0.008), lorsqu'il existait une bactériémie (p=0.0001) et lorsqu'il y avait un examen bactériologique des sécrétions bronchiques positif (p=0.05). Le taux de mortalité a été réduit de 53% à 28% lorsque la réexploration chirurgicale a été effectuée régulièrement toutes les 48 heures plutôt qu'à la demande. Malgré un taux élevé de fistules gastrointestinales associées avec la méthode de drainage ouvert (30%), cette approche paraît un succès et nous la recommandons dans le traitement de la pancréatite nécrotique, infectée ou pas.
Resumen
Ciento dos pacientes con pancreatitis aguda necrotizante fueron tratados con un método combinado de necrosectomía, drenaje abierto por laparostomía y exploraciones repetidas. La gravedad de la pancreatitis fue determinada mediante el indice APACHE II (promedio de 15 en el momento de la admisión). 87 (85%) pacientes fueron clasificados como necrosis pancreática infectada y sólo 15 (15%) como necrosis pancreática. Globalmente murieron 36 (35%) pacientes, la mayoría por falla orgánica multisistémica. La sobrevida fue significativamente afectada por la contaminatión bacteriana de la necrosis pancreática (p=0.008), la bacteremia (p=0.0001) y la infección bronquial (0.05). La mortalidad pudo ser significativamente reducida, de 53% a 28%, mediante el cambio de reexplorar según demanda a reexplorar regularmente cada 48 horas. A pesar de que el “empaquetamiento abierto” (“open packing”) apareció asociado con una alla incidencia de fistulas gastrointestinales (30%), este método parece ser un aproche razonable y exitoso en el tratamiento de la necrosis pancreática infectada.
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Függer, R., Schulz, F., Rogy, M. et al. Open approach in pancreatic and infected pancreatic necrosis: Laparostomies and preplanned revisions. World J. Surg. 15, 516–520 (1991). https://doi.org/10.1007/BF01675650
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DOI: https://doi.org/10.1007/BF01675650