TIMING OF SURGICAL INTERVENTION IN NECROTIZING'PANCREATITIS

Abstract

Background: Timing of first surgical intervention in (suspected) infected necrotizing pancreatitis (NP) is thought to influence outcome. Aim: To determine the impact of timing of surgical intervention for NP on outcome. Methods: Retrospective study of 445 acute pancreatitis patients in a tertiary referral center over a 10 year period and a systematic review of single center studies comprising 25 or more patients with NP published in the previous decade. Results: Fifty-three patients underwent surgical intervention for NP, 42 (79%) of whom had been referred. Median timing of first intervention was 28 days. Eighty-three percent had infected necrosis. Fifty-five percent had organ failure. The mortality rate was 36%. Sixteen patients were operated within 14 days, 11 patients from day 15-28 and 26 patients on day 29 or later (29+ subgroup). APACHEII, Ranson scores and preoperative organ failure and intensive care stay were comparable between the three subgroups. The 29+ subgroup received prophylactic antibiotics for a longer period of time (4, 17 and 25 days, P = 0.0001) and Candida and antibiotic resistant organisms were more often cultured from the (peri-)pancreatic necrosis (1, 1 and 9, P = 0.022). Mortality was decreased in the 29+ subgroup (75, 45 and 8%, P = 0.0001). During the second half of the study, necrosectomy was further postponed (20 versus 43 days, P = 0.062) and mortality decreased (47 versus 22%, P = 0.085). To compare our results with previous work, 11 studies with a total of 1136 patients were included in a systematic review. Median surgical patient volume was 8.3 patients per year (5.3-15.6), timing of surgical intervention 26 days (3-31 days) and mortality 25% (6-56%). Also in the review a significant correlation was observed between timing of intervention and mortality (R = −0.603, P = 0.050, 95% CI −2.10 to −0.02). Conclusions: Postponing necrosectomy in NP until after the fourth week is associated with decreased mortality, prolonged use of antibiotics and increased incidence of Candida and antibiotic resistant organisms.