title: Predictors of surgery in patients with severe acute pancreatitis managed by the step-up approach.
abstract: BACKGROUND
  Initial management of severe acute pancreatitis (SAP) is conservative. As a step-up approach, percutaneous catheter drainage (PCD) with saline irrigation is reported to be effective. Factors leading to surgery are unclear.
  
  
  METHODS
  In this ongoing prospective study, 70 consecutive patients with SAP were recruited. As a step-up approach, all patients initially received medical management and later underwent PCD and surgery as per the indication.
  
  
  RESULTS
  Of the 70 consecutive patients with SAP, 14 were managed medically, 29 managed with PCD alone, whereas 27 required surgery after initial PCD. Sepsis reversal was achieved with PCD alone in 62.5%. The curative efficacy of PCD alone was in 27 patients (48%). Overall mortality in the whole group was 24%. On univariate analysis, factors significantly affecting surgical intervention included initial acute physiology and chronic health evaluation (APACHE) II score, APACHE II score at first intervention, sepsis reversal by PCD within a week, number of organs failed, organ failure within a week of the onset of disease, number of bacteria isolated per patient, renal failure, respiratory failure, Escherichia coli, computerized tomography severity index score at admission, parenteral nutrition requirement before or after radiological intervention, maximum extent of necrosis of more than 50% of the pancreas, and extrapancreatic necrosis. On multivariate analysis, renal failure (P = -0.03), APACHE II score at first intervention (P = -0.006), and the number of bacteria isolated per patient (P = -0.01) remained independent predictors of surgery. An APACHE II score of more than 7.5 at first intervention (PCD) had the ability to predict surgery with a sensitivity of 88.9% and a specificity of 69%.
  
  
  CONCLUSIONS
  PCD reversed sepsis in 62% and avoided surgery in 48% of the patients. Reversal of sepsis within a week of PCD, APACHE II score at first intervention (PCD), and organ failure within a week of the onset of disease could predict the need for surgery in the early course of disease.
authors.affiliation: Division of Surgical Gastroenterology, Department of General Surgery, Post Graduate Institute of Medical Education Research, Chandigarh 160012, India.
authors.forename: Raghavendra Yalakanti
authors.initials: RY
authors.lastname: Babu
authors.forename: Rajesh
authors.initials: R
authors.lastname: Gupta
authors.forename: Mandeep
authors.initials: M
authors.lastname: Kang
authors.forename: Deepak Kumar
authors.initials: DK
authors.lastname: Bhasin
authors.forename: Surinder Singh
authors.initials: SS
authors.lastname: Rana
authors.forename: Rajinder
authors.initials: R
authors.lastname: Singh
mesh_terms: D018806:APACHE; D000208:Acute Disease; D000328:Adult; D002404:Catheterization; D004322:Drainage; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D063305:Organ Dysfunction Scores; D010195:Pancreatitis / Q000150:complications / Q000175:diagnosis / Q000601:surgery / Q000628:therapy*; D019283:Pancreatitis, Acute Necrotizing / Q000150:complications / Q000601:surgery / Q000628:therapy*; D011379:Prognosis; D018805:Sepsis / Q000150:complications