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Necrotizing Pancreatitis: An Update on Current Management

Flavio G Rocha, Eric Benoit, Peter Banks, Koenraad Mortele, Michael J Zinner, Edward E Whang, Stanley W Ashley
Brigham and Women's Hospital, Boston, MA

Objective-A conservative strategy can be applied to patients with necrotizing pancreatitis, reserving surgery for documented infection or organized necrosis. Use of image-guided percutaneous drainage at our institution has become increasingly prevalent. We therefore reviewed our experience with the management of this disease.
Design- Outcomes study
Setting- Tertiary referral center
Patients- Retrospective review of 689 patients with acute pancreatitis between 2000 and 2005.
Main Outcome Measures- Patient demographics, infection status, type of intervention, and survival were analyzed.
Results- Sixty-four (9%) patients had documented pancreatic necrosis. The overall mortality rate was 15%. Twenty-nine (45%) patients were managed conservatively with one death (4% mortality). Seven (11%) patients underwent surgical intervention alone for documented infection or organized necrosis with one death (14% mortality). Seventeen (27%) patients were treated by percutaneous drainage followed by surgical intervention. Of those, 11 had sterile necrosis while 6 were infected. There were 2 deaths in this group (12% mortality). Eleven (17%) patients underwent percutaneous drainage alone without surgery with 6 deaths (55% mortality). All 3 patients with infected necrosis died while 3 of 8 patients with sterile necrosis died in this cohort. Most of these patients would not have been candidates for surgery.
Conclusion: The overall incidence and mortality of necrotizing pancreatitis at our institution has not changed. Conservative therapy is still indicated for patients with necrotizing pancreatitis in the absence of infected necrosis or clinical deterioration. Surgical debridement remains the most effective and definitive strategy for treatment of infected necrosis or organized necrosis. Percutaneous drainage may serve as a useful adjunct allowing for delayed surgery in critically ill patients. However, its role as isolated therapy in pancreatic necrosis needs to be evaluated further.

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