COLON INVOLVEMENT IN NECROTIZING PANCREATITIS: INCIDENCE, RISK FACTORS, AND OUTCOMES
Megan Nicolas*, Thomas K. Maatman, Alexandra M. Roch, M A. Heimberger, Kyle A. Lewellen, Hayder H. Al-Azzawi, Eugene P. Ceppa, Michael G. House, Attila Nakeeb, Christian Schmidt, Nicholas J. Zyromski
Surgery, Indiana University, Inadianapolis, IN
Necrotizing pancreatitis (NP) is characterized by a profound inflammatory response with local and systemic implications. Mesocolic involvement can compromise colonic blood supply and lead to ischemic complications. We hypothesized the development of colonic complications in NP severely effects morbidity and mortality, and, therefore, sought to evaluate its incidence, risk factors, and outcomes.
647 NP patients treated between 2005-2017 were retrospectively reviewed to identify patients with colon complications, including: ischemia, perforation, fistula, stricture/obstruction, and fulminant C. difficile colitis. Clinical characteristics were evaluated to identify risk factors and effect of colon involvement on morbidity and mortality. Where applicable, independent groups t-tests and Pearson's correlation or Fisher's exact tests were performed. Odds ratios (OR) are reported with a 95% confidence interval (CI) where appropriate. P-values of ≤0.05 were accepted as statistically significant.
Colon complications were seen in 11% (69/647) of NP patients. Ischemia was the most common pathology (n=29) followed by perforation (n=18), fistula (n=12), stricture/obstruction (n=7), and fulminant C. difficile colitis (n=3). The median time from NP onset to the operative management of colonic complication was 44 days (range 8-466). Statistically significant risk factors include tobacco use (OR 2.0, 95% CI 1.2-3.3, p=0.007), coronary artery disease (OR 2.3, 95% CI 1.2-4.3, p=0.01), and any organ failure (OR 3.4, 95% CI 2.0-5.7, p<0.001). The most common location of pathology was the right colon (n=27, 39.1%), followed by the left colon (n=23, 33.3%), and the entire colon (n=18, 26.1%). One patient (1.4%) had isolated sigmoid colon involvement. Colon intervention was concurrent with pancreatic debridement in 39 patients (56.5%) and after initial pancreatic debridement in 25 patients (36.2%); five patients (7.2%) did not require pancreatic debridement. Initial operative management of colon pathology included: left colectomy (n=22, 31.9%), right colectomy (n=21, 30.4%), total abdominal colectomy (n=18, 26.1%), colorrhaphy (n=4, 5.8%), cecostomy tube (n=3, 4.3%), or sigmoidectomy (n=1, 1.4%). Reoperation for progression of colonic disease was required in eight patients (11.6%). Necrotizing pancreatitis patients with colonic involvement had significantly increased morbidity (Table 1) and mortality (18.8% vs. 7.6%, p=0.005) when compared to those without colonic involvement.
Colon involvement in necrotizing pancreatitis is common; clinical deterioration should prompt evaluation for colonic pathology. Risk factors include tobacco use, coronary artery disease, and organ failure. Colonic involvement in necrotizing pancreatitis is associated with substantial morbidity and high mortality.
Table 1: Outcomes in necrotizing pancreatitis with and without colon involvement.
|Outcome||Colon involvement (n=69)||Control (n=578)||p-value|
|Respiratory failure, %||63.8||28.7||<0.001|
|Renal failure, %||43.5||20.4||<0.001|
|Cardiovascular failure, %||36.2||11.9||<0.001|
|Any organ failure, %||68.1||32.7||<0.001|
|Mean time to resolution, days (SEM)||360 (44)||174 (7)||<0.0001|
|Mean # of procedures (SEM)||5.6 (0.5)||2.3 (0.1)||<0.0001|
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