Factors that have resulted in the reduced mortality of acute pancreatitis from 1978–1997

Abstract

A Prospective study of 4 time periods, i.e. 1978-82, 1983-87, 1988-92, 1993-97 showed a steady decline in the mortality of acute pancreatitis from 13.5% to 8%, to 7% and lastly, to 5% respectively. During this time, the incidence of pancreatitis has escalated so that the overall mortality has increased despite the reduction of percentage terms. The increase of acute cases in the later periods is almost totally due to an exponential rise in gallstone pancreatitis and a few miscellaneous forms such as ERCP, etc. The most impressive decrease in mortality has been in the patients with severe acute pancreatitis (SAP) from about 50% in the early period to between 12-17% over the last 4 yrs. The factors contributing to this decrease were: 1983-87 the introduction of the common signs of severity, i.e. Ranson's and Bank's signs leading to immediate ICU therapy, improved ICU care, particularly for cardiac, pulmonary and renal complications. 1988-92 CT scan became included in the severity score especially with regard to intrapancreatic necrosis, ICU techniques advanced and prolonged drainage of pancreatic abscess or necrotic tissue was introduced. In the middle of this period, skinny needle aspiration for the diagnosis of infection became popular. From 1992-97 the value of early antibiotics in pancreatic necrosis became established, multiple organ system failure was treated intensively with the return to use of Dextran in some centers, octreotide, somatostatin and PAF. Selective bacterial decontamination of the gut was introduced and newer antibiotics which penetrated the necrotic tissue were introduced. The place of emergency ERCP in non-alcohol induced pancreatitis became established particularly in cholangitis. Treatment of complications took great strides with both endoscopic and radiologic nonsurgical techniques taking a quantum leap for the treatment of cysts, persistent necrosis, ascites. Trials of newer agents, i.e. platelet activating factor antagonist have yet to be shown conclusively to decrease the early mortality. Conclusion: This 20 year personal prospective study has shown an impressive decline in the mortality of acute pancreatitis from 13.5-5% especially SAP. Early markers of severity and cytokine antagonists have yet to prove efficacy in reducing the mortality further.