Indications And Timing Of Converting To Open Pancreatic Necrosectomy For MSAP/SAP Treated With Percutaneous Catheter Drainage

Objective To explore the indications and timing of converting to open pancreatic necrosectomy(OPN)for moderately severe acute pancreatitis/severe acute pancreatitis(MSAP/SAP)treated with percutaneous catheter drainage(PCD)through retrospective analysis.Methods The clinical data of patients with MSAP/SAP treated with PCD as the initial surgical intervention between January 2008 to June 2016 in the First Affiliated Hospital and Second Affiliated Hospital of of Anhui Medical University were collected.According to weather the treatment convert to OPN after PCD,the patients were divided into PCD group(141 cases)and PCD+OPN group(27 cases),and the PCD+OPN group was divided into the cured group(21 cases)and the death group(6 cases)according to the results of the PCD+OPN treatment.The different of baseline data,admission assessment(organ failure,APACHE II score,Rason score,etc),the time between first PCD and onset,indwelling time and number of catheterization,and mortality were compared between each groups was analyzed for the indications and prognostic factors of OPN.The data were analyzed by SPSS 17.0,the univariate and multivariate analysis were done using the chi-square test and the measurement data were analyzed using independent sample t test.Results There is 16.1%(27/168)of a total of 168 patients treated with PCD converted to OPN.Indications for OPN as follow:(1)inadequate and disease progression(16 cases),(2)gastrointestinal or abdominal cavity bleeding(4 cases),digestive tract fistula(4 cases),digestive tract fistula with abdominal cavity bleeding(1 case),lose replace path after catheter displacement(2 cases).The mortality of PCD+OPN group was higher than that of PCD group,but the difference was not statistically significant(22.2% vs 19.1%,p=0.741).The PCD+OPN group was higher than the PCD group(62.9% vs 36.2%,p=0.044)over the age of 60,in the PCD+OPN group,the death group was also higher than that of cured group,but the difference was not statistically significant(p=0.897),however,its overall age was significantly higher than that of the cured group(64.3±8.9years vs 48.8±13.8years,p=0.016).The hospitalization time,ICU time,proportion of ICU 2 times of the PCD+OPN group was higher than the PCD group(100.1±37.5days vs 33.8±16.4days,p<0.001;39.7±31.8days vs 13.4±8.8days,p<0.001;2.8% vs 22.2%,p<0.001).The proportion of multiple organ failure and Rason score of the PCD+OPN group on admission were higher than those of PCD group,and the difference was statistically significant(37.1% vs 17.0%,p=0.034;4.8±1.3 vs 4.2±1.2,p=0.020).The time begin to enteral nutrition of PCD+OPN group was later than PCD group(18.7±10.9days vs 13.6±7.5days,p=0.003).The score of APACHE II at first PCD and proption of APACHE II>8 of PCD+OPN group was higher than the PCD group(18.7±10.9 vs 13.6±7.5,p=0.003;18.5% vs 2.8%,p=0.001).The proption of MOF and sepsis within one week after PCD of PCD+OPN group was higher than the PCD group(40.7% vs 19.1%,p=0.031;48.1% vs 13.4%,p<0.001).The number of PCD catheters per patient and the proption of replacement of thick tube in PCD+OPN group was higher than the PCD group(2.7±1.4 catheters vs 11.9±1.1 catheters,p=0.001;70.7% vs 26.2%,p<0.001).In the PCD+OPN group,the time between onset and first PCD was 3~127(26.8±16.5)days,and the time converted to OPN from first PCD was 2~68(22 + 13.7)days,and each of the cases was given 1~7(3.7±1.2)catheter,and 12 cases(44.4%)were replaced with a more thick diameter drainage tube.The proption of MOF and necrotic collection in the head of thepancreas and whole pancreas combine with extra-pancreas of the death group was higher than that of cured group(83.3% vs 23.8%,p=0.035;4.8% vs 50%,p=0.011;9.5% vs 50%,p=0.042).During the period of PCD converted to OPN,the number of PCD catheters per patient and the total time of drain duration in the cure group was less than death group(2.5±1.0catheters vs 3.5±1.2catheters,p=0.043;21.7±12.0d vs 33.2±10.2d,p=0.048).The difference of methods and time of operation between the cure group and death group was not statistically significant.There were 3 cases new onset of organ failure in the death group,compared with 0 in the cure group,the difference was statistically significant(p=0.001).And there was no statistic difference in the other complication rate in two group was not statistically significant.The reasons of PCD+OPN death group as follows: multiple organ failure(3 cases),septic shock(1 case),intraperitoneal hemorrhage(1 case),and sudden cardiac arrest(1 case,because of hyperkalemia).All those cases complicated with sepsis.Conclusions(1)The main indication of PCD converted to OPN was inadequate drainage and disease progression.(2)Over the age of 60,MOF on admission,necrotic collection in the head of the pancreas and whole pancreas combine with extra-pancreas,multiple tube insertion and replacement of thick tube,and MOF and sepsis within one week after PCD were unfavorable factors.When the inadequate drainage cropped up and have no way to improve,worsening systemic toxemic symptoms after PCD,OPN should be taken into consideration in time.(3)The major prognostic factor of OPN were the too many times and long time of PCD,new onset of organ failure after PCD or OPN.