BACKGROUND: The indications for surgical intervention in acute pancreatitis have changed significantly in the last two decades. In the present study medical charts of patients with acute pancreatitis treated at our institution were analyzed to assess the effects of changed surgical treatment on patient outcome.
METHODS: 138 patients with severe pancreatitis, radiologically defined as Balthazar grade E and/or perfusion deficit in computed tomography (CT), were primarily treated or referred to our institution between 1980-97. Patients with unexpected pancreatic necrosis during abdominal exploration were included. Severity of the disease (Ranson Score), indication for surgical intervention, number of surgical procedures, and mortality were compared during three study periods: 1980-85 (period I), 1986-90 (period II), and 1991-97 (period III). During period I, patients were explored within 72 hours on the basis of secondary organ failure, whereas in period II surgery was reserved for patients who had secondary organ failure together with pancreatic necrosis seen on CT. In period III, the aim was to operate as late as possible in the presence of pancreatic necrosis or when there was the suspicion of infected pancreatic necrosis.
RESULTS: Ranson Score points were comparable in the three groups. The strategy of limiting indications for surgery resulted in a decrease of surgically treated patients from 68% (period I) to 42% (period II) and 35% (period III)(period I vs. III p=0.003). Likewise, surgical intervention occurred progressively later from period I to III. In period I, 73% of operations were performed earlier than 72 hours after admission, compared to 29% in period II and 38% in period III (period I vs. III p=0.04). In each of the periods, mortality of patients with late surgical intervention (after 72 hours from admission) was less than with early abdominal exploration (earlier than 72 hours) (period I 57% vs. 42%, period II 40% vs. 16%, period III 50% vs. 15%, all p>0.05, n.s.). Overall mortality of patients with severe pancreatitis was reduced from 39% (period I) to 15% (period II) and 13% (period III)(period I vs. III p=0.006).
CONCLUSIONS: The present study supports delayed surgical intervention in severe acute pancreatitis. Early intervention results in often unnecessary procedures with an increase in mortality. When possible, prolonged observation allows selection of patients who are likely to benefit from delayed surgical intervention or conservative treatment.