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Timing of Surgical Intervention After Percutaneous Catheter Drainage (Pcd) in Step up Approach of Severe Acute Pancreatitis
Sunil D. Shenvi*1, Rajesh Gupta1, Rajinder Singh1, Madhu Khullar2, Mandeep Kang3, Surinder S. Rana4, Deepak K. Bhasin4
1Division of Surgical Gastroenterolgy,Department of General surgery, PGIMER, Chandigarh, India; 2Department Of Experimental Medicine, PGIMER, Chandigarh, India; 3Department Of Radiodiagnosis, PGIMER, Chandigarh, India; 4Department Of Medical Gastroenterolgy, PGIMER, Chandigarh, India
Aims and Objectives -To determine appropriate timing of surgical intervention after PCD in infected pancreatic necrosis (IPN), as a part of step up approach and to see change in morbidity and mortality after changing the interval of surgery after PCD.
Materials and methods - Randomized controlled trial was tried to find out the optimal timings of surgery following PCD in a patients with IPN who are not improving significantly within one week of PCD. The trail has to be stopped prematurely because of difficulty in recruitment of patients and apparent increase in the mortality in patients undergoing surgery early following PCD compared to patients who were managed with continued treatment of PCD. Following this rest 32 patients were managed by extended treatment with PCD in prospective manner and weekly inflammatory and nutritional markers were monitored in these patients. Surgery was performed in these patients when required. Out of 40 patients managed prospectively, 36 patients who underwent continued treatment with PCD were analyzed.
Results - Duration between first PCD and surgery ranged from 10- 58 days with a mean of 41±16.15days and median of 43 days. The efficacy of Extended treatment PCD alone in achieving complete recovery in patients with infected pancreatic necrosis was 68.5%.Overall mortality in the present study was 15.1%.Disease specific morality in PCD alone group was 5.5%. Disease specific mortality in surgery group was 42.8%.ICU stay and number of Extrapancreatic necrosis in posterior pararenal space were predicting need of surgery on univariate and multivariate analysis. Need of mechanical ventilation and organ failure at admission had high odd's ratio when factors affecting mortality were compared in patients managed by PCD alone and patients managed by surgery after PCD. Serial estimation of inflammatory and nutritional markers does not help in predicting the timing of surgery.
Conclusion- Early surgery following PCD results in high mortality in our randomized controlled study. Timing of surgery cannot be fixed and needs to be tailored depending on patient's response to extended treatment of PCD.
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