Severe acute pancreatitis: nonsurgical treatment of infected necroses

In acute pancreatitis, infection of necrosis is associated with a substantial mortality of 15% to >50% even if immediate necrosectomy, the recommended standard treatment, is performed, mainly because of the patients' critical systemic and unstable local conditions at the time of manifestation of infection. We investigated whether this dreaded complication can be managed conservatively.

We evaluated 88 consecutive patients with severe (APACHE II score, > or =11; Ranson score, > or =4) acute necrotizing pancreatitis who received ICU treatment including early antibiotic prophylaxis. Twenty-eight patients were included who developed infection of necroses, verified by fine needle aspiration, 19 +/- 6 days after admission. No patient received urgent surgery; rather, in all patients, nonsurgical therapy was continued after adapting the antibiotic regimen to bacteriology. In the further course, 12 patients were excluded due to refractory local complications eventually requiring surgical treatment 36 +/- 14 days after diagnosis of infection.

Sixteen patients (APACHE II score: 18.1 [11-33]; Ranson score, 5.9 [4-10]) were managed with medical treatment alone. Six patients recovered without further complications; 10 patients (62%) developed single or multiple organ failure, and 2 died (mortality, 12%).

These data suggest that in patients with acute necrotizing pancreatitis and infected necroses, surgery can be avoided without compromising prognosis and outcome.