Hospital Álvaro Cunqueiro de Vigo, Vigo, Spain.
Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy.
Updates Surg. 2020 Dec;72(4):1097-1103. doi: 10.1007/s13304-020-00764-z. Epub 2020 Apr 18.
Severe acute pancreatitis complicated by infection is associated with high mortality. Invasive treatment is indicated in the presence of infected (suspected) pancreatic and/or peripancreatic necrosis (IPN) in the absence of response to intensive medical support. Step-up approach (SUA) has been demonstrated to lower complication rate compared to upfront open surgery. However, this approach has not been associated with lower mortality, and no factors have been studied that could help to identify the high risk patients. In this study, we aimed to analyse those factors associated with mortality following the invasive treatment of IPN, focusing on the role of surgical necrosectomy. A retrospective and observational study based on a multicentre prospective database was conducted. The database was coordinated by the Hospital General Universitario de Alicante, Spain and the Spanish Association of Pancreatology. Demographics, clinical data, and laboratory and imaging findings were collected. Atlanta 2012 criteria were considered to classify acute necrotizing pancreatitis and for the definition of IPN. Step-up approach was used in all centres with the intention of avoiding surgery whenever possible. Surgical necrosectomy was performed by open approach. From January 2013 to October 2014, a total of 1655 patients with the diagnosis of acute pancreatitis were included in our database. 1081 were recruited for the final analysis. Out of them, 205 (19%) were classified into acute necrotizing pancreatitis. 77 (8.3%) patients underwent invasive treatment of INP and were included in our study. Overall mortality was 29.9%. Upfront endoscopic or percutaneous drainage was performed in 60 (77.9%) patients and mortality was 26.6%. Out of 60, 22 (36.6%) patients subsequently received rescue surgery; mortality in rescue surgery group was 18.3%. Upfront surgery was carried out in 17 (22.1%) patients; mortality in this group was 41%. At univariate analysis, surgical necrosectomy, extrapancreatic infection, immunosuppression and de-novo haemodialysis were associated with mortality. At multivariate analysis, only surgical necrosectomy was significantly associated with mortality (p = 0.002 OR 3.89). Surgical approach for IPN is associated with high mortality rate. However, these data should be interpreted with caution, since we are not able to assess whether this occurs due to the need of surgery as the only resort when the other approaches are not feasible or fail.
严重的急性胰腺炎并发感染与高死亡率相关。在没有对强化医疗支持产生反应的情况下，如果存在感染（疑似）的胰腺和/或胰周坏死（IPN），则需要进行有创治疗。阶梯式方法（SUA）已被证明与直接开腹手术相比，并发症发生率更低。然而，这种方法与较低的死亡率无关，也没有研究任何因素可以帮助识别高危患者。在这项研究中，我们旨在分析侵袭性治疗 IPN 后与死亡率相关的因素，重点关注手术坏死清除术的作用。这是一项基于多中心前瞻性数据库的回顾性和观察性研究。该数据库由西班牙阿利坎特综合医院和西班牙胰腺病学会协调。收集了人口统计学、临床数据以及实验室和影像学发现。采用 2012 年亚特兰大标准对急性坏死性胰腺炎进行分类，并对 IPN 进行定义。所有中心均采用阶梯式方法，尽可能避免手术。手术坏死清除术采用开腹方式进行。2013 年 1 月至 2014 年 10 月，我们的数据库共纳入了 1655 例急性胰腺炎患者。其中 1081 例被纳入最终分析。在这些患者中，205 例（19%）被归类为急性坏死性胰腺炎。77 例（8.3%）接受了 IPN 的有创治疗，并纳入了我们的研究。总体死亡率为 29.9%。60 例患者（77.9%）行早期内镜或经皮引流，死亡率为 26.6%。其中 22 例（36.6%）患者随后接受了挽救性手术，挽救性手术组死亡率为 18.3%。17 例（22.1%）患者行早期手术，该组死亡率为 41%。单因素分析显示，手术坏死清除术、胰外感染、免疫抑制和新开始血液透析与死亡率相关。多因素分析显示，只有手术坏死清除术与死亡率显著相关（p=0.002 OR 3.89）。IPN 的手术方法与高死亡率相关。然而，这些数据的解释应谨慎，因为我们无法评估这是否是由于在其他方法不可行或失败时，手术成为唯一手段而导致的。
