Operative vs Non-Operative Management in Sterile Necrotizing Pancreatitis

Background: The clinical management of sterile pancreatic necrosis is still a matter of debate. In this study we analyzed the clinical course and outcome of patients with sterile necrotizing pancreatitis treated surgically versus nonsurgically. Study Design: Between May 1982 and December 1993, 249 patients with necrotizing pancreatitis (NP) entered this study, of which 172 (69 percent) had intraoperatively or fine needle aspiration-proven sterile NP. One hundred seven of 172 patients underwent surgery (S group) with necrosectomy and continuous postoperative closed lavage and 65 of 172 were treated by nonsurgical means (NS group). Results: Median Ranson and admission APACHE II scores were 4.7 (range, 1 to 10) and 11 (range, 1 to 29) in the S group, significantly higher than those in the NS group with 3.0 (range, 0 to 6) (p=0.022) and 8 (range, 1 to 23) (p=0.036). After 48 hours of intensive care treatment, APACHE II scores persisted at 10.5 (range, 1 to 29) in the S group and decreased to 6 (range, 0 to 15) (p=0.013) in the NS patients. Median Creactive protein (CRP) levels on admission were 179 mg/L and 68.5 mg/L (p=0.023), respectively. Within 72 hours, 61 (94 percent) of 65 NS-managed patients responded to intensive care therapy, whereas organ complications persisted or increased and thus led to surgery in the S group. Mortality rates were 13.1 percent in the surgically treated patients and 6.2 percent in the nonsurgically treated patients (p=NS). Conclusions: Most patients with limited and sterile pancreatic necrosis respond to intensive care treatment. Indication for surgery in sterile NP should be based on persisting or advancing organ complications despite intensive care therapy. APACHE II scores and adraission CRP levels represent a helpful tool in decision making for surgical or nonsurgical management of NP.