BACKGROUND: Despite improvement in management, the mortality rate of severe pancreatitis remains 30-50%. Management of patients with severe pancreatitis is complicated by variability in clinical presentation, the difficulty in early diagnosis of surgical complications and lack of agreement about the timing and type of surgical intervention. We present our experience with a High Risk Protocol (HRP) and Staged Abdominal Re-explorations (STAR) for the management of patients with severe pancreatitis.
Patient and METHODS: This retrospective study included 21 patients with severe pancreatitis admitted to a tertiary care hospital in Illinois from July 1991 through June 1997 managed prospectively by HRP and STAR. HRP is a prospectively designed protocol and care map which categorizes patients with severe pancreatitis into subgroups utilizing Cardio / Pulmonary / Renal stability and dynamic computerized tomography (CT). Criteria for diagnosis of acute pancreatitis included clinical, laboratory and radiological tests. Diagnosis of severe pancreatitis was based on Ranson criteria score on admission of more than three. Indications for STAR were evidence of pancreatic necrosis exceeding 50% of the gland by CT, clinical failure of medical management or the presence of bacteria in the peripancreatic tissue. STAR involved planned re-operation every 48 hours via a standard subcostal incision with interval packing of the retroperitoneum and closure of the abdomen until the retroperitoneal space was free of necrotic material on two successive explorations. Average age of the patients was 61 years (range 38-91 years). STAR and HRP were used in 18 patients, two patients were transfers and one refused the final operation.
RESULTS: Overall mortality rate was 23%(5/21). When STAR was used mortality rate was 16% (3/18). Patients underwent an average of 4±2 operations. The average interval between operations was two days. There were seventeen complications in eight patients: six fistulas, four abscesses, six wound dehiscences and one hemorrhage from a gall bladder fossa.
CONCLUSIONS: This study demonstrates the first application of a single surgical and medical protocol, which resulted in acceptable mortality and morbidity rates. This study presents a simple guideline, by which surgeons who infrequently manage this disease can provide surgical consultation.