Outcome of severe acute pancreatitis: is there a role for conservative management of infected pancreatic necrosis?

Background: Infected pancreatic necrosis is associated with high morbidity and mortality and is mandatory for surgical or radiological intervention. A selected group of patients with CT evidence of infected pancreatic necrosis and a comparatively lower APACHE score may be clinically stable throughout the course of their illness.

Methods: Case records of 52 patients with severe acute pancreatitis admitted from October 2000 to September 2005 were retrospectively analysed to assess the feasibility of conservative management of infected pancreatic necrosis. CT evidence of retroperitoneal air pockets, deteriorated clinical condition, sepsis and positive blood culture were used to diagnose infected pancreatic necrosis.

Results: In the 52 male patients reviewed, 24 patients had infected pancreatic necrosis. Eighteen patients who had progressively deteriorated clinical conditions required surgical intervention; five patients of whom (27.8%) died. Six patients with transient end organ dysfunction and stable clinical conditions were treated with prolonged administration of antibiotics and ICU support. All these patients recovered and discharged from the hospital, and no symptoms or readmission happened during follow-up of 6-44 months.

Conclusions: Selected patients with infected pancreatic necrosis who are clinically stable with transient end organ dysfunction can be treated conservatively with a favourable outcome. Necrosectomy associated with high morbidity and mortality in these patients can be avoided. The need for intervention should be individualized and based on clinical conditions of the patients.