Abstract
BACKGROUND:
Percutaneous catheter drainage (PCD) is a minimally invasive intervation for severe acute pancreatitis (SAP). This study was undertaken to compare the results of surgery and ultrasound-guided PCD in the treatment of 32 patients with SAP, and to direct clinicians to the most optimal approach for SAP.
METHODS:
In the 32 patients, 19 were proved to have deteriorated clinical signs or symptoms, extensive fluid exudation, and necrosis confirmed by computed tomography (CT) and they underwent operative debridement and drainage. For extensive fluid exudation or necrosis, complete liquefaction and safe catheter implantation, the other 13 patients were given PCD.
RESULTS:
The mortality rate of the surgery group was 26.3%, much higher than that of the PCD group (0%). There was a significant difference between the two groups (P=0.044). The mean time for recovery of the serum C-reactive protein (CRP) level was 43.8 days in the surgery group, which was significantly longer than that of the PCD group (23.8 days) (P=0.034).
CONCLUSION:
Early PCD guided by ultrasound could decrease the mortality of patients with severe acute pancreatitis, alleviate life-threatening inflammatory complications, and avoid unnecessary emergency operation.
KEY WORDS: Percutaneous catheter drainage, Operation, Severe acute pancreatitis, Clinical efficacy
INTRODUCTION
Percutaneous catheter drainage (PCD) was reported as a minimally invasive intervention for severe acute pancreatitis (SAP), [1] and approximately 54% of patients with acute necrotizing pancreatitis can be successfully treated with CT-guided PCD. SAP is a rapid progressive disease with a high mortality rate and a high incidence of life-threatening complications. Bai et al[2] reported that the overall mortality rate of SAP was 11.8% in China and 10%-40% in western countries.[3]
By CT images, acute pancreatitis could be classified into five grades, and grades D and E are defined as SAP.[4] The Ranson score system is commonly used to evaluate the severity of acute pancreatitis, and a higher score indicates a poor prognosis.[5] In the present series of 32 patients with SAP who were retrospectively studied, 19 patients had been undergone surgery and 13 patients had been subjected to PCD. Both groups were compared in terms of clinical outcomes, prognosis and laboratory findings.
METHODS
Patients
The 32 patients were treated from January 2002 to September 2008 at the Department of Gastroenterology and Surgery of the Second Affiliated Hospital of Zhejiang University School of Medicine. The mean age of these patients (19 men, 13 women) was 51.9 years (range 27-82 years). SAP was defined by the following criteria: epigastric pain; elevated serum amylase level greater than normal limit; morphological abnormalities shown by CT or MRI in the pancreas; peri-pancreatic extensive fluid exudation and/or necrosis; abscess; and organ failure. Moreover, others included APACH-II≥8, Ranson score≥3 and C-reactive protein (CRP) level≥150mg/L.[6] The 32 patients met the above criteria. Etiologically, biliary tract disease was found in 18 patients, endoscopic retrograde cholangiopancreatography (ERCP)-caused disease in 1, alcohol abuse in 9, hyperlipidemia in 1, and unknown cause in 3. The mean Ranson score of the 32 patients was 4.6 points. Three patients were classified with SAP of grade D and 29 patients with SAP of grade E according to CT findings.
Methods
In the 32 SAP patients, 19 patients underwent surgery and 13 patients underwent PCD. The 19 patients in the surgery group were found to have extensive pancreatic and/or peripancreatic fluid collection and severe local or systemic complications. They subsequently received operative debridement and drainage. For extensive fluid collection or necrosis, complete liquefaction, and safe catheter implantation, the 13 patients underwent PCD. During the procedures, drainage fluid culture and irrigation were performed routinely. All of the SAP patients were subjected to ultrasound, CT and determination of CRP level after 48 hours of PCD. The PCD was performed in sterilized conditions by experienced radiologists. The size of catheter ranged from 8 to 10 Fr. (Hakko Ultrasonically Guided One-Step Drainage Set Types-S, Hakko CO., Ltd., Chikuma-shi, Nagano, Japan). The levels of serum CRP, blood amylase as well as other clinical parameters were measured.
Statistical analysis
Variables of the patients were analyzed by the Mann-Whitney U test and the Chi-square test with SPSS 16.0 software (Chicago, USA). P<0.05 was considered statistically significant.
RESULTS
The surgery group
The patients underwent operative debridement and drainage within 12.7 days (1-46) after admission, and 3 of them were re-operated upon. In the surgery group (19 patients), 7(36.8%) developed sepsis, 5 (26.3%) had acute respiratory distress syndrome (ARDS), 3(15.8%) had multiple organ dysfunction syndrome (MODS) and 5 patients (26.3%) died.
The PCD group
In this group, PCD lasted 10.5 days (range 1-32 days), and the duration of catheterization was 37.1 days (range 15-68 days). Four patients presenting pseudocysts (30.8%) were completely cured after PCD. Because the catheter was blocked, 3 patients were drainaged again. Since a large amount of fluid was collected, 2 patients were given PCD again. Sepsis occurred in 4 patients (30.8%), ARDS in 2 (10.5%), MODS in 1(5.3%) and death in none of the patients. The total mortality rate in this group was 15.6%. There was a significant difference in mortality rate between the surgery and PCD groups (26.3% vs 0%, P=0.044). The mean time for the recovery of CRP level was much longer in the surgery group than in the PCD group (44.4 vs 25.7, P=0.034) (Table 1). The clinical parameters of the PCD group are shown in Table 2. In addition, dynamic contrast enhanced CT images of PCD in a male SAP patient are shown in Figure.
Table 1.
Comparative study between the surgery and PCD groups
Table 2.
Clinical parameters of 13 patients with SAP in the PCD group
Figure.
Dynamic pancreatic changes in a 45-year-old male SAP patient during PCD. A: Extensive necrosis and fluid collection of the pancreatic head, body and tail in 48 hours after admission (arrow); B: Extensive necrosis and fluid collection of the pancreas on the day of PCD (arrow); C: Complication of pyseudocysts occurred in the head and tail of the pancreas (arrow); D:Complete absorption of pancreatitis after 40 days of PCD (arrow).
DISCUSSION
A retrospective study of 262 SAP patients showed that the mortality rate was 20.5% for 39 patients in a surgery group and 8.1% for 223 patients in a non-surgery group.[7] A significant difference was observed between the two groups (20.5% vs 8.1%, P<0.05). This indicates that early surgery could not prevent pathological changes, but could increase the risk of postoperative infection, systemic inflammatory response syndrome (SIRS) and severe metabolic disorder.[7] Bradley et al[8] reported that early surgery might worsen internal environment and increase the risk of infection and that the mortality rate could be as high as 30%-40%. In this study the mortality rate of the surgery group was 26.3%, which was higher than that of the PCD group (0%, P=0.044).
Szentkereszty et al[9] postulated that early PCD played an important role in the prognosis of SAP. With the progression of SAP, the rate of bacterial infection could be 40%-70%.[10] In our series, the 32 SAP patients were treated by PCD in addition to the administration of antibiotics which could penetrate into the pancreatic tissues early. The mortality rate was 15% in those patients with infected pancreatic necrosis. Obviously PCD could be an alternative approach for SAP.[11] In a multicenter, randomized, double-blind trial, 50 SAP patients were given meropenem antibiotics, and the other 50 SAP patients received placebo. The results of the trial showed that there was no significant difference in mortality rate (P=0.476).[12] In our study there was no significant difference in antibiotics administered and courses of SAP between the surgery group and the PCD group (P>0.05), and the mortality rate of the surgery group was 26.3%. Hence we presumed that early PCD combined with use of antibiotics might decrease the release of inflammatory mediators and the recovery of infection.
CRP level was thought to play important roles in predicting the severity of acute pancreatitis and its prognosis.[13] As a response marker of acute phase inflammation, CRP level within 24-48 hours after the onset of the disease is used to evaluate the severity of acute pancreatitis. Its sensitivity and specificity could be 80%.[14] Makela et al[15] reported that prognosis of the disease would be poor when CRP level was ≥150mg/L, and elevated CRP level might prolong the hospital stay of patients and increase the mortality rate. Novalho et al[16] treated 30 SAP patients by PCD, and 19 of them were cured completely. The CRP levels were 172.8mg/L and 102.5mg/L before and after PCD respectively (P<0.05). They recognized that PCD could avoid emergency surgery and decrease the risk of infection. We predict that the longer the CRP level recovery, the worse the outcome.
CRP level can be determined to assess the severity of SAP within the first 48 hours, but CT or CT severity index (CTSI) might be more precise.[17] In the present study the mean time for the recovery of CRP level was 43.8 days in the surgery group, which was much longer than that in the PCD group (23.8 days). There was a significant difference between the two groups (P=0.034). We consider that early PCD could inhibit inflammatory response or decrease endotoxin absorption of severe local or systemic complications.
In conclusion, early PCD could decrease the mortality rate of patients with SAP, alleviate life-threatening inflammatory complications, and avoid unnecessary emergency operation.
Footnotes
Funding: The study was supported by the grants from the National Health Key Special Fund (200802112), Health Department Fund (2007A093, 2007A094), Traditional Chinese Medicine Bureau Fund (2007ZA019), and the Natural Science Fund of Zhejiang Province (Y208001).
Ethical approval: Not needed.
Competing interest: None.
Contributors: All authors have contributed to this study. Ai XB wrote the first draft under the supervision of Pan WS.
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