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Learning Curve Effect on ‘Step Up Approach' for Management of Severe Acute Pancreatitis
Rajesh Gupta*1, Rahul Gupta1, Sunil Shenvi2, Raghavendra B. Yelakanti3, Rohit K. Nimje4, Abhishek Chandna4, Surinder S. Rana5, Mandeep Kang6, Rajinder Singh1, Deepak K. Bhasin5
1Surgical Gastroenterology Division, Postgraduate Institute of Medical Education and Research, Chandigarh, India; 2Transplant Surgery, Medical University of South Carolina, Charleston, SC; 3Hepatobiliary and Liver Transplantation, Medanta Medicity, Gurgaon, Haryana, India; 4General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India; 5Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India; 6Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Background
This study was conducted to see if there is learning curve effect on outcome of ‘Step up approach’ in a single surgical Unit in a tertiary care centre.
Methods
Patients of SAP referred to Division of Surgical Gastroenterology from April 2008 to October 2015 were distributed into 3 time periods: Group 1 - April 2008 to August 2011, Group II - September 2011 to September 2014 and Group III -October 2014 to October 2015. The three groups were compared for learning curve effect.
Results
There were total of 170 patients in this period. There were 60 patients each in Group I and II and 50 in Group III. When compared to group I and II, patients in Group III had higher APACHE II score at first intervention (8.28 vs 9.32 vs 9.82, p = 0.073), significantly higher modified CTSI score (8.7 vs 9.1 vs 9.6, p = 0.003), signifiantly more patients with complete necrosis (9 vs 20 vs 20, p = 0.009) and extrapancreatic necrosis (22 vs 39 vs 44, p = 0.000). Microbial spectrum also changed during this period with Escherichia coli being the most common organism in Group I and II (39 vs 33 vs 17, p = 0.004) while Klebsiella pneumoniae was the most common organism in Group III (8 vs 15 vs 18, p = 0.021). Number of PCD procedures performed per patient were highest in Group I and progressive reduction in number of procedures was observed over time (5.1 vs 3.7 vs 2.2, p = 0.002). Significantly less number of patients required surgery in Group III (29 vs 19 vs 9, p = 0.003). Mean duration of hospital stay (47 vs 47 vs 29, p = 0.000) and duration of PCD/drain (66 vs 45 vs 29, p = 0.000) was significantly less in Group III. There was no significant difference in the mortality rate between the three groups (18 vs 14 vs 18, p = 0.3) despite increasing severity of disease.
Conclusion
This is first study of its kind to analyze the impact of learnng curve on the outcome of Step up approach in the management of SAP. This study demonstrates that with increasing experience, sicker patients can be managed successfully with fewer PCD procedures, lesser need of surgery, shorter hospital stay and shorter duration of drainage without any significant change in the mortality rate.


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