Treatment strategy against infection: clinical outcome of continuous regional arterial infusion, enteral nutrition, and surgery in severe acute pancreatitis.
BACKGROUND
In severe acute pancreatitis (SAP), infectious complications are the main contributors to high mortality. Since 1995, we have performed continuous regional arterial infusion of protease inhibitor and antibiotics (CRAI) and enteral nutrition (EN) as prevention therapies against infection. When infected pancreatic necrosis was proven, surgical intervention was adapted. The aim of this study was to investigate the clinical outcome of these treatments.


METHODS
We examined the relationship between the historical change of treatment strategy and clinical outcome. We divided 84 patients with acute necrotizing pancreatitis into two groups, CRAI (-) and CRAI (+), and compared the outcome. We divided 145 patients with SAP into two groups, EN (-) and EN (+), and compared the outcome. We also analyzed the outcome of surgical treatment.


RESULTS
In the CRAI (+) group, the incidence of infection, the frequency of surgery, and the mortality rate were lower than those in CRAI (-) group: 34% versus 51%, 27% versus 63% (P < 0.05), and 37% versus 54%, respectively. In the EN (+) group, the frequency of surgery and the mortality rate were lower than those in the EN (-) group: 23% versus 32% and 19% versus 35% (P < 0.05), respectively. These improvement effects were manifest in stage 3 (9 < or = Japanese Severity Score < or = 14). Treatment outcome of necrosectomy for infected pancreatic necrosis was still poor. Bleeding and abscess-gut fistula were postoperative life-threatening complications.


CONCLUSIONS
CRAI and EN may improve the clinical outcome of SAP, reducing infection and averting pancreatic surgery.
Yasuda
Takeo
T
Department of Gastroenterological Surgery, Kobe University Graduate School of Medical Sciences, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan.
Ueda
Takashi
T
Takeyama
Yoshifumi
Y
Shinzeki
Makoto
M
Sawa
Hidehiro
H
Nakajima
Takahiro
T
Matsumoto
Ippei
I
Fujita
Tsunenori
T
Sakai
Tetsuya
T
Ajiki
Tetsuo
T
Fujino
Yasuhiro
Y
Kuroda
Yoshikazu
Y
D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D001424:Bacterial Infections / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D001550:Benzamidines; D044963:Biopsy, Fine-Needle; D004359:Drug Therapy, Combination; D004750:Enteral Nutrition / Q000379:methods*; D005260:Female; D005341:Fibrinolysin / Q000037:antagonists & inhibitors; D005500:Follow-Up Studies; D006146:Guanidines / Q000008:administration & dosage; D006801:Humans; D015378:Imipenem / Q000008:administration & dosage; D015994:Incidence; D007261:Infusions, Intra-Arterial; D007564:Japan / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000379:methods*; D019283:Pancreatitis, Acute Necrotizing / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D017410:Practice Guidelines as Topic; D011480:Protease Inhibitors / Q000008:administration & dosage*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents; D001550:Benzamidines; D006146:Guanidines; D011480:Protease Inhibitors; D015378:Imipenem; D005341:Fibrinolysin; C032855:nafamostat
J Gastrointest Surg. 2006 Feb;10(2):278-85
16455462
Pancreas. 2002 Nov;25(4):325-30
12409824
Br J Surg. 1999 Aug;86(8):1020-4
10460637
JPEN J Parenter Enteral Nutr. 2006 Mar-Apr;30(2):143-56
16517959
Surgery. 2007 Jan;141(1):51-8
17188167
J Gastrointest Surg. 1997 Jan-Feb;1(1):40-6; discussion 46-7
9834329
Am J Surg. 2001 Jun;181(6):571-5
11513789
Br J Surg. 1996 Jul;83(7):930-3
8813777
Pancreas. 2001 Aug;23(2):148-56
11484917
Br J Surg. 1997 Dec;84(12):1665-9
9448611
Ann Surg. 1998 Nov;228(5):676-84
9833806
Br J Surg. 2001 Jul;88(7):975-9
11442530
Surgery. 1966 Dec;60(6):1235-41
5297061
J Hepatobiliary Pancreat Surg. 2006;13(1):48-55
16463211
Ann Surg. 2000 Nov;232(5):619-26
11066131
J Hepatobiliary Pancreat Surg. 2002;9(4):423-8
12483263
Crit Care Med. 2004 Dec;32(12):2524-36
15599161
J Hepatobiliary Pancreat Surg. 2003;10(6):419-24
14714161
Am J Surg. 1996 Apr;171(4):394-8
8604829
Pancreatology. 2002;2(6):565-73
12435871
Br J Surg. 2003 Dec;90(12):1542-8
14648734
JPEN J Parenter Enteral Nutr. 1997 Jan-Feb;21(1):14-20
9002079
Surgery. 2005 May;137(5):499-505
15855920
Surgery. 2005 Jul;138(1):28-39
16003313
J Hepatobiliary Pancreat Surg. 2001;8(3):216-20
11455482
Pancreatology. 2001;1(6):668-73
12120252
Pancreas. 2004 May;28(4):369-73
15097852
Am J Dig Dis. 1969 Jun;14(6):415-9
5305886
Surg Gynecol Obstet. 1974 Jul;139(1):69-81
4834279
J Hepatobiliary Pancreat Surg. 2006;13(1):42-7
16463210
Crit Care Med. 1985 Oct;13(10):818-29
3928249