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Timing of Surgical Intervention in Necrotizing Pancreatitis
Marc G. H. Besselink, MD; Thomas J. Verwer, MD; Ernst J. P. Schoenmaeckers, MD; Erik Buskens, MD, PhD; Ben U. Ridwan, MD; Maarten R. Visser, MD, PhD; Vincent B. Nieuwenhuijs, MD, PhD; Hein G. Gooszen, MD, PhD

Objective: To determine the effect of timing of surgical intervention for necrotizing pancreatitis.Design: Retrospective study of 53 patients and a systematic review. Setting: A tertiary referral center. Main Outcome Measure: Mortality. Results: Median timing of the intervention was 28 days. Eighty-three percent of patients had infected necrosis and 55% had preoperative organ failure. The mortality rate was 36%. Sixteen patients were operated on within 14 days of initial admission, 11 patients fromday 15 to 29, and 26 patients on day 30 or later. This latter group received preoperative antibiotics for a longer period (P .001), and Candida species and antibiotic-resistant organisms were more often cultured from the pancreatic or peripancreatic necrosis in these patients (P=.02). The 30-day group also had the lowest mortality (8% vs

75% in the 1 to 14–days group and 45% in the 15 to 29–days group, P .001); this difference persisted when outcome was stratified for preoperative organ failure. During the second half of the study, necrosectomy was further postponed (43 vs 20 days, P = .06) and mortality decreased (22% vs 47%, P=.09). We also reviewed 11 studies with a total of 1136 patients. Median surgical patient volume was 8.3 patients per year (range, 5.3-15.6), median timing ofsurgical intervention was 26 days (range, 3-31), and median mortality was 25% (range, 6%-56%). We observed a significant correlation between timing of intervention and mortality (R=−0.603; 95% confidence interval, −2.10 to −0.02; P=.05).
Conclusion: Postponing necrosectomy until 30 days

after initial hospital admission is associated with decreased mortality, prolonged use of antibiotics, andincreased incidence of Candida species and antibioticresistant organisms. Arch Surg. 2007;142(12):1194-1201 recent European survey demonstrated that there is still no consensus on this subject, as 43% of surgeons prefer intervention within the first 14 days, whereas 29% prefer to wait for at least 21 days.4 Furthermore, it was recently suggested that the delay in surgical intervention in ANP may leadto prolonged use of (prophylactic) antibiotics, leading to an increased incidence of Candida infections and antibiotic-resistant organisms.5 This study describes our increasing experience in postponing surgical intervention in necrotizing pancreatitis. This strategy may lead to necrosectomy being performed after the upper end of the interval suggested by the IAP guidelines, ie, after day 28.Furthermore, we assessed the impact of postponing surgical intervention on the use of antibiotics, fungal infections, and antibiotic resistance. Finally, we performed a systematic literature review to further explore potential associations between timing of surgical intervention and outcome.

Author Affiliations: Departments of Surgery (Drs Besselink, Verwer, Schoenmaeckers, Nieuwenhuijs, andGooszen) and Microbiology (Drs Ridwan and Visser), and Julius Center for Health Sciences and Primary Care (Dr Buskens), University Medical Center Utrecht, Utrecht, the Netherlands.

IMING OF SURGICAL INTERvention in acute necrotizing pancreatitis (ANP) has changed substantially during the last decade, from early necrosectomy, without respect to the state of infection, to delayed operation in case ofdocumented or suspected infection of pancreatic necrosis. It has been hypothesized that postponing surgical intervention allows the immune system to encapsulate the necrotic tissue, thus technically facilitating necrosectomy and potentially reducing mortality.1 The beneficial effect of this strategy was confirmed in a randomized controlled trial comparing intervention within 72 hours of onset...
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