Background: Current guidelines recommend performance of fine needle aspiration (FNA) in patients with severe acute pancreatitis (SAP) and signs of sepsis. Infected necrosis in those patients is an indication for surgical intervention. Previously, we found high mortality in patients operated early in the course of the disease based on positive FNA. Currently we do not perform early FNAs and primarily treat patients with SAP conservatively.We evaluated the impact of this concept on outcome in SAP.
Methods: Prospective analysis of patients with SAP since 09/2003 (group 1) and comparison with retrospectively analyzed patients from 03/2000 until 08/2003 (group 2).
Results: Group1: 20 consecutive patients with SAP were treated according to the new concept. All had > 50% necrosis on CT. Upon admission the scores were: APACHE II: 16 ± 2.2, SOFA: 6.5 ± 1.1, Ranson 3.9 ± 0,23. CRP on day 3 was 283 ± 25 mg/l. One patient underwent early surgery and died during hospital stay. Six patients needed late surgery due to secondary complications and survived. One out of 13 conservatively treated patient died (7.7%). CT-guided drainage was performed in one patient with abdominal compartment due to pseudocyst formation. Total mortality in group 1 was 10 %. Admission scores of group 2 (20 patients)were not statistically different. All patients were operated following positive FNA. Incidence of organ failure (OF) (divided into four-OF, three-OF, two-OF and one-OF) was 60%, 35%, 5% and 0% compared to 15%, 45%, 10% and 5% in group 1. However, degree of pancreatic damage was the same with equal degree of necrosis on CT and same percentage of endocrine insufficiency (80% in both groups). Mortality in group 2 was 45%.
Conclusion: Mortality of patients with SAP treated conservatively without FNA had a significant lower mortality compared with patients treated in accordance to current guidelines implying operation upon detection of infected necrosis by FNA. Difference in treatment included avoidance of FNA and surgery within the first 3-4 weeks, if clinically possible. We suggest that FNA should be avoided within the first 3 weeks of SAP in a stable patient regardless secondary organ complications since surgery increases mortality during this early phase independent from the infection of pancreatic necrosis.