Organ Failure Plus Necrosis Doubles Mortality in Acute Pancreatitis

Acute pancreatitis patients with both organ failure and infected pancreatic necrosis have a risk of death that is twice as high as that of patients with one or the other complication alone, Dr. Maxim S. Petrov and colleagues reported in the September issue of Gastroenterology.

The finding, from a meta-analysis that included nearly 1,500 patients, could provide “strong justification” for revision of the Atlanta system of pancreatic disease severity, “with this worst-prognosis group being termed ‘critical’ acute pancreatitis,” wrote the authors.

Dr. Petrov and his colleagues, of the surgery department at the University of Auckland in New Zealand, searched the Medline, Scopus, and Embase databases for studies published between Jan. 1, 1993, and Aug. 1, 2009, that examined either organ failure or necrotic infection in acute pancreatitis patients. Studies that did not specifically assess in-hospital mortality were excluded.

The start date of the search, in 1993, corresponds with the publication of the Atlanta system of pancreatic disease classification, which considers local pancreatic complications and extrapancreatic organ failure to be the major determinants of severity and divides patients into “mild” and “severe” categories.

A total of 513 abstracts were identified for further investigation, and ultimately 14 papers, representing 1,478 patients with acute pancreatitis, were included. Seven of the studies were conducted in Europe, three in North America, two in Asia, and two in Central and South America (Gastroenterology 2010 Sept.1 [doi:10.1053/j.gastro.2010.06.010]).

Among the entire cohort of acute pancreatitis patients, 600 had organ failure (OF, for a prevalence of 41%), and 314 had infected pancreatic necrosis (IPN, prevalence of 21%).

Overall in-hospital mortality among the entire patient population was 13% (191 patients), according to Dr. Petrov and his colleagues. The deaths included 87 of 387 patients with OF only (mortality of 22% in this group) and 10 of 93 patients with IPN only (mortality of 11%).

However, when the researchers looked at all patients who had OF, irrespective of their IPN status, the mortality crept up to 30% (179 out of 600 total patients with OF). A similar scenario occurred among all IPN patients, including those with both IPN and OF, where the mortality hit 32% (102 out of 314 total IPN patients).

These findings are “consistent with the Atlanta classification that admits that the presence of OF and/or IPN determines severity,” wrote the authors. However, “the present study takes this further by demonstrating that both OF and IPN are equivalent determinants of severity,” a point of controversy among studies that have found OF to be the primary determinant, regardless of whether local pancreatic complications are present.

However, in patients who had both OF and IPN, mortality jumped to 43% (92 deaths out of 213 total patients with OF and IPN). This finding amounted to a highly significant relative risk of death of 1.94, compared with OF patients who did not have IPN (95% confidence interval 1.32-2.85, P = .0007).

The outcome “did not appear to depend on the number of failed distant organs, definition of OF, indications for surgery, type of study, year of publication, and study setting,” wrote the authors, although the risk was significant only in English-language studies, versus papers included in the meta-analysis that were published in other languages. Most of the 14 papers were written in English, but there was one study each written in Russian, Spanish, and Turkish.

“The determinants of disease severity in acute pancreatitis continue to be the subject of debate,” wrote Dr. Petrov. “From a practical perspective, this study identifies a subgroup of patients with acute pancreatitis with both OF and IPN who have a substantially higher mortality” than patients who have one complication or the other, or who have neither, wrote Dr. Petrov.

Acknowledgment of this special, critically ill category of patients “will improve clinical assessment of individual patients during the course of acute pancreatitis, communication between caregivers, and comparison between groups in clinical studies.”

Dr. Petrov and his colleagues reported no conflicts of interest related to this study.

Acute pancreatitis patients with both organ failure and infected pancreatic necrosis have a risk of death that is twice as high as that of patients with one or the other complication alone, Dr. Maxim S. Petrov and colleagues reported in the September issue of Gastroenterology.

The finding, from a meta-analysis that included nearly 1,500 patients, could provide “strong justification” for revision of the Atlanta system of pancreatic disease severity, “with this worst-prognosis group being termed ‘critical’ acute pancreatitis,” wrote the authors.

Dr. Petrov and his colleagues, of the surgery department at the University of Auckland in New Zealand, searched the Medline, Scopus, and Embase databases for studies published between Jan. 1, 1993, and Aug. 1, 2009, that examined either organ failure or necrotic infection in acute pancreatitis patients. Studies that did not specifically assess in-hospital mortality were excluded.

The start date of the search, in 1993, corresponds with the publication of the Atlanta system of pancreatic disease classification, which considers local pancreatic complications and extrapancreatic organ failure to be the major determinants of severity and divides patients into “mild” and “severe” categories.

A total of 513 abstracts were identified for further investigation, and ultimately 14 papers, representing 1,478 patients with acute pancreatitis, were included. Seven of the studies were conducted in Europe, three in North America, two in Asia, and two in Central and South America (Gastroenterology 2010 Sept.1 [doi:10.1053/j.gastro.2010.06.010]).

Among the entire cohort of acute pancreatitis patients, 600 had organ failure (OF, for a prevalence of 41%), and 314 had infected pancreatic necrosis (IPN, prevalence of 21%).

Overall in-hospital mortality among the entire patient population was 13% (191 patients), according to Dr. Petrov and his colleagues. The deaths included 87 of 387 patients with OF only (mortality of 22% in this group) and 10 of 93 patients with IPN only (mortality of 11%).

However, when the researchers looked at all patients who had OF, irrespective of their IPN status, the mortality crept up to 30% (179 out of 600 total patients with OF). A similar scenario occurred among all IPN patients, including those with both IPN and OF, where the mortality hit 32% (102 out of 314 total IPN patients).

These findings are “consistent with the Atlanta classification that admits that the presence of OF and/or IPN determines severity,” wrote the authors. However, “the present study takes this further by demonstrating that both OF and IPN are equivalent determinants of severity,” a point of controversy among studies that have found OF to be the primary determinant, regardless of whether local pancreatic complications are present.

However, in patients who had both OF and IPN, mortality jumped to 43% (92 deaths out of 213 total patients with OF and IPN). This finding amounted to a highly significant relative risk of death of 1.94, compared with OF patients who did not have IPN (95% confidence interval 1.32-2.85, P = .0007).

The outcome “did not appear to depend on the number of failed distant organs, definition of OF, indications for surgery, type of study, year of publication, and study setting,” wrote the authors, although the risk was significant only in English-language studies, versus papers included in the meta-analysis that were published in other languages. Most of the 14 papers were written in English, but there was one study each written in Russian, Spanish, and Turkish.

“The determinants of disease severity in acute pancreatitis continue to be the subject of debate,” wrote Dr. Petrov. “From a practical perspective, this study identifies a subgroup of patients with acute pancreatitis with both OF and IPN who have a substantially higher mortality” than patients who have one complication or the other, or who have neither, wrote Dr. Petrov.

Acknowledgment of this special, critically ill category of patients “will improve clinical assessment of individual patients during the course of acute pancreatitis, communication between caregivers, and comparison between groups in clinical studies.”

Dr. Petrov and his colleagues reported no conflicts of interest related to this study.

Acute pancreatitis patients with both organ failure and infected pancreatic necrosis have a risk of death that is twice as high as that of patients with one or the other complication alone, Dr. Maxim S. Petrov and colleagues reported in the September issue of Gastroenterology.

The finding, from a meta-analysis that included nearly 1,500 patients, could provide “strong justification” for revision of the Atlanta system of pancreatic disease severity, “with this worst-prognosis group being termed ‘critical’ acute pancreatitis,” wrote the authors.

Dr. Petrov and his colleagues, of the surgery department at the University of Auckland in New Zealand, searched the Medline, Scopus, and Embase databases for studies published between Jan. 1, 1993, and Aug. 1, 2009, that examined either organ failure or necrotic infection in acute pancreatitis patients. Studies that did not specifically assess in-hospital mortality were excluded.

The start date of the search, in 1993, corresponds with the publication of the Atlanta system of pancreatic disease classification, which considers local pancreatic complications and extrapancreatic organ failure to be the major determinants of severity and divides patients into “mild” and “severe” categories.

A total of 513 abstracts were identified for further investigation, and ultimately 14 papers, representing 1,478 patients with acute pancreatitis, were included. Seven of the studies were conducted in Europe, three in North America, two in Asia, and two in Central and South America (Gastroenterology 2010 Sept.1 [doi:10.1053/j.gastro.2010.06.010]).

Among the entire cohort of acute pancreatitis patients, 600 had organ failure (OF, for a prevalence of 41%), and 314 had infected pancreatic necrosis (IPN, prevalence of 21%).

Overall in-hospital mortality among the entire patient population was 13% (191 patients), according to Dr. Petrov and his colleagues. The deaths included 87 of 387 patients with OF only (mortality of 22% in this group) and 10 of 93 patients with IPN only (mortality of 11%).

However, when the researchers looked at all patients who had OF, irrespective of their IPN status, the mortality crept up to 30% (179 out of 600 total patients with OF). A similar scenario occurred among all IPN patients, including those with both IPN and OF, where the mortality hit 32% (102 out of 314 total IPN patients).

These findings are “consistent with the Atlanta classification that admits that the presence of OF and/or IPN determines severity,” wrote the authors. However, “the present study takes this further by demonstrating that both OF and IPN are equivalent determinants of severity,” a point of controversy among studies that have found OF to be the primary determinant, regardless of whether local pancreatic complications are present.

However, in patients who had both OF and IPN, mortality jumped to 43% (92 deaths out of 213 total patients with OF and IPN). This finding amounted to a highly significant relative risk of death of 1.94, compared with OF patients who did not have IPN (95% confidence interval 1.32-2.85, P = .0007).

The outcome “did not appear to depend on the number of failed distant organs, definition of OF, indications for surgery, type of study, year of publication, and study setting,” wrote the authors, although the risk was significant only in English-language studies, versus papers included in the meta-analysis that were published in other languages. Most of the 14 papers were written in English, but there was one study each written in Russian, Spanish, and Turkish.

“The determinants of disease severity in acute pancreatitis continue to be the subject of debate,” wrote Dr. Petrov. “From a practical perspective, this study identifies a subgroup of patients with acute pancreatitis with both OF and IPN who have a substantially higher mortality” than patients who have one complication or the other, or who have neither, wrote Dr. Petrov.

Acknowledgment of this special, critically ill category of patients “will improve clinical assessment of individual patients during the course of acute pancreatitis, communication between caregivers, and comparison between groups in clinical studies.”

Dr. Petrov and his colleagues reported no conflicts of interest related to this study.