Conservative Treatment Comparable With Surgery in Infected Pancreatic Necrosis

Among patients with infected pancreatic necrosis, both surgical necrosectomy and conservative treatment with antibiotics had comparable mortality rates, Dr. Pramod Kumar Garg and colleagues reported in the December issue of Clinical Gastroenterology and Hepatology.

However, over 10 years, the more conservatively managed patients had a better mortality rate than did the necrosectomy patients, the authors added.

"There has been no randomized comparative trial between conservative and surgical therapy in patients with IPN [infected pancreatic necrosis], primarily because conservative management was never considered a viable treatment option," wrote Dr. Garg of the department of gastroenterology at the All India Institute of Medical Sciences in New Delhi (Clin. Gastroenterol. Hepatol. 2010 December [doi:10.1016/j.cgh.2010.04.011]).

He added that although "the present study has substantiated the emerging concept of primary conservative treatment in patients with infected pancreatic necrosis ... [it] in no way undermines the importance of surgery, preferably minimally invasive, in those patients who really merit surgical necrosectomy."

Dr. Garg and colleagues looked retrospectively at patients with infected pancreatic necrosis who were admitted to their facility in New Delhi. All cases were confirmed on culture.

Patients were divided into two groups. Group 1 was admitted between January 1997 and December 2002, and underwent surgery as their first, primary option, per hospital policy at the time. Patients who were not surgical candidates because of comorbid risk factors received conservative management.

There were 30 patients with IPN in this first group, 18 of whom had surgery after a median of 25 days and 12 of whom received conservative management.

Group 2 included patients who were admitted between January 2003 and December 2006. By this time, the institution’s protocol had changed to make aggressive medical treatment in an ICU – including combination antibiotics, organ support, intensive nutritional support, and percutaneous drainage, if required – the primary treatment. If medical treatment failed, patients underwent surgery.

This second group included 50 IPN patients, 40 of whom were managed conservatively and 10 of whom received open necrosectomy after a median of 47 days.

In group 1, the mortality rate for surgical patients was 66% (12 deaths) and 8% in the conservatively managed group (1 death), the authors reported. The difference was not statistically significant.

In group 2, 3 (33%) of the 10 patients who were treated surgically died, and of the 40 patients who were treated conservatively, 11 (28%) died. This difference did not reach statistical significance, either.

Overall, that translated to a mortality rate of 28% for group 2, compared with a rate of 43% in group 1, which also was not statistically significant.

"However, of the total 80 patients with IPN over the 10-year period, there was a significantly higher survival among patients treated medically [40 of 52 patients, or 77%] compared with those treated surgically [13 of 28 patients, or 46%]" (P = .005), wrote the authors.

The researchers then looked prospectively at a third group of IPN patients who were admitted between January 2007 and December 2008. Group 3 was handled like group 2, with aggressive antibiotic treatment in an ICU as the primary treatment, followed by surgery if medical treatment failed. This third group included 27 patients with IPN (19 managed medically and 8 who had surgery).

Two patients died following surgery, whereas six died following medical treatment, for an overall mortality of 30% in group 3, which was similar to the overall mortality of group 2, "thus confirming the results of conservative management for IPN," wrote Dr. Garg and associates.

The researchers noted some limitations to their study, primarily that it was not randomized. "However, in the absence of convincing data about the success of conservative treatment for IPN, such a randomized trial would have been considered unethical and thus, perhaps was not possible," they added.

Dr. Garg and colleagues stated that they had no financial disclosures or conflicts of interest, and no financial support was declared for this study.

Among patients with infected pancreatic necrosis, both surgical necrosectomy and conservative treatment with antibiotics had comparable mortality rates, Dr. Pramod Kumar Garg and colleagues reported in the December issue of Clinical Gastroenterology and Hepatology.

However, over 10 years, the more conservatively managed patients had a better mortality rate than did the necrosectomy patients, the authors added.

"There has been no randomized comparative trial between conservative and surgical therapy in patients with IPN [infected pancreatic necrosis], primarily because conservative management was never considered a viable treatment option," wrote Dr. Garg of the department of gastroenterology at the All India Institute of Medical Sciences in New Delhi (Clin. Gastroenterol. Hepatol. 2010 December [doi:10.1016/j.cgh.2010.04.011]).

He added that although "the present study has substantiated the emerging concept of primary conservative treatment in patients with infected pancreatic necrosis ... [it] in no way undermines the importance of surgery, preferably minimally invasive, in those patients who really merit surgical necrosectomy."

Dr. Garg and colleagues looked retrospectively at patients with infected pancreatic necrosis who were admitted to their facility in New Delhi. All cases were confirmed on culture.

Patients were divided into two groups. Group 1 was admitted between January 1997 and December 2002, and underwent surgery as their first, primary option, per hospital policy at the time. Patients who were not surgical candidates because of comorbid risk factors received conservative management.

There were 30 patients with IPN in this first group, 18 of whom had surgery after a median of 25 days and 12 of whom received conservative management.

Group 2 included patients who were admitted between January 2003 and December 2006. By this time, the institution’s protocol had changed to make aggressive medical treatment in an ICU – including combination antibiotics, organ support, intensive nutritional support, and percutaneous drainage, if required – the primary treatment. If medical treatment failed, patients underwent surgery.

This second group included 50 IPN patients, 40 of whom were managed conservatively and 10 of whom received open necrosectomy after a median of 47 days.

In group 1, the mortality rate for surgical patients was 66% (12 deaths) and 8% in the conservatively managed group (1 death), the authors reported. The difference was not statistically significant.

In group 2, 3 (33%) of the 10 patients who were treated surgically died, and of the 40 patients who were treated conservatively, 11 (28%) died. This difference did not reach statistical significance, either.

Overall, that translated to a mortality rate of 28% for group 2, compared with a rate of 43% in group 1, which also was not statistically significant.

"However, of the total 80 patients with IPN over the 10-year period, there was a significantly higher survival among patients treated medically [40 of 52 patients, or 77%] compared with those treated surgically [13 of 28 patients, or 46%]" (P = .005), wrote the authors.

The researchers then looked prospectively at a third group of IPN patients who were admitted between January 2007 and December 2008. Group 3 was handled like group 2, with aggressive antibiotic treatment in an ICU as the primary treatment, followed by surgery if medical treatment failed. This third group included 27 patients with IPN (19 managed medically and 8 who had surgery).

Two patients died following surgery, whereas six died following medical treatment, for an overall mortality of 30% in group 3, which was similar to the overall mortality of group 2, "thus confirming the results of conservative management for IPN," wrote Dr. Garg and associates.

The researchers noted some limitations to their study, primarily that it was not randomized. "However, in the absence of convincing data about the success of conservative treatment for IPN, such a randomized trial would have been considered unethical and thus, perhaps was not possible," they added.

Dr. Garg and colleagues stated that they had no financial disclosures or conflicts of interest, and no financial support was declared for this study.

Among patients with infected pancreatic necrosis, both surgical necrosectomy and conservative treatment with antibiotics had comparable mortality rates, Dr. Pramod Kumar Garg and colleagues reported in the December issue of Clinical Gastroenterology and Hepatology.

However, over 10 years, the more conservatively managed patients had a better mortality rate than did the necrosectomy patients, the authors added.

"There has been no randomized comparative trial between conservative and surgical therapy in patients with IPN [infected pancreatic necrosis], primarily because conservative management was never considered a viable treatment option," wrote Dr. Garg of the department of gastroenterology at the All India Institute of Medical Sciences in New Delhi (Clin. Gastroenterol. Hepatol. 2010 December [doi:10.1016/j.cgh.2010.04.011]).

He added that although "the present study has substantiated the emerging concept of primary conservative treatment in patients with infected pancreatic necrosis ... [it] in no way undermines the importance of surgery, preferably minimally invasive, in those patients who really merit surgical necrosectomy."

Dr. Garg and colleagues looked retrospectively at patients with infected pancreatic necrosis who were admitted to their facility in New Delhi. All cases were confirmed on culture.

Patients were divided into two groups. Group 1 was admitted between January 1997 and December 2002, and underwent surgery as their first, primary option, per hospital policy at the time. Patients who were not surgical candidates because of comorbid risk factors received conservative management.

There were 30 patients with IPN in this first group, 18 of whom had surgery after a median of 25 days and 12 of whom received conservative management.

Group 2 included patients who were admitted between January 2003 and December 2006. By this time, the institution’s protocol had changed to make aggressive medical treatment in an ICU – including combination antibiotics, organ support, intensive nutritional support, and percutaneous drainage, if required – the primary treatment. If medical treatment failed, patients underwent surgery.

This second group included 50 IPN patients, 40 of whom were managed conservatively and 10 of whom received open necrosectomy after a median of 47 days.

In group 1, the mortality rate for surgical patients was 66% (12 deaths) and 8% in the conservatively managed group (1 death), the authors reported. The difference was not statistically significant.

In group 2, 3 (33%) of the 10 patients who were treated surgically died, and of the 40 patients who were treated conservatively, 11 (28%) died. This difference did not reach statistical significance, either.

Overall, that translated to a mortality rate of 28% for group 2, compared with a rate of 43% in group 1, which also was not statistically significant.

"However, of the total 80 patients with IPN over the 10-year period, there was a significantly higher survival among patients treated medically [40 of 52 patients, or 77%] compared with those treated surgically [13 of 28 patients, or 46%]" (P = .005), wrote the authors.

The researchers then looked prospectively at a third group of IPN patients who were admitted between January 2007 and December 2008. Group 3 was handled like group 2, with aggressive antibiotic treatment in an ICU as the primary treatment, followed by surgery if medical treatment failed. This third group included 27 patients with IPN (19 managed medically and 8 who had surgery).

Two patients died following surgery, whereas six died following medical treatment, for an overall mortality of 30% in group 3, which was similar to the overall mortality of group 2, "thus confirming the results of conservative management for IPN," wrote Dr. Garg and associates.

The researchers noted some limitations to their study, primarily that it was not randomized. "However, in the absence of convincing data about the success of conservative treatment for IPN, such a randomized trial would have been considered unethical and thus, perhaps was not possible," they added.

Dr. Garg and colleagues stated that they had no financial disclosures or conflicts of interest, and no financial support was declared for this study.