Intensive Care Med (1985) 11:107-109 I n t e n s i v e Care M e d i c i n e © Springer-Verlag 1985

Editorial

Changing concepts in the evaluation and treatment of acute severe pancreatitis

F. Bonnet, N, Rotman and P. L. Fagniez

Department of Intensive Care, HSpital Henri Mondor, Cr6teil, France

Accepted: l0 December 1984

Acute necrotizing pancreatitis is one of the most se- vere abdominal emergencies. In order to reduce its high mortality, various medical and surgical manage- ments have been proposed in the past years [24] and some progress has been made in two main areas: first- ly in the diagnosis and evaluation of the disease, and secondly in its therapy.

A method of evaluating the severity of acute pan- creatitis has been proposed by Ranson et al. [20]. In a retrospective study, 11 early variables, including clini- cal and biological parameters, were found to be relat- ed with the occurrence of complications and death. These criteria were confirmed as reliable in a prospec- tive study by the same authors and in studies by others using comparable parameters [8, 21, 22]. The main advantage of this method is that it makes it possible to select groups of patients with the same severity score and hence to compare the effects of different forms of treatment between patients. It has, however, two drawbacks, namely the necessity of a 48-h period to collect all the prognostic variables and the impossibili- ty of a repetitive evaluation.

More recently, a simplified physiological score, designed for acute conditions, has been proposed. Simple clinical and biological parameters are collected and given a certain weighting according to their de- gree of abnormality [11]. This type of evaluation needs to be validated by prospective studies in acute pancreatitis.

The diagnosis and evaluation of acute necrotizing pancreatitis has also been improved in recent years, by the use of computerized tomography (CT scan). A CT scan shows not only the pancreatic lesion, but also the intraabdominal, extrapancreatic, extension of the disease. The necrotized pancreas appears to be en- larged, inhomogeneous or sometimes completely de- stroyed. The most severe pancreatitis is characterized by extrapancreatic phlegmonous extensions localized

in the peripancreatic space, the lesser sac, the left an- terior pararenal space and less frequently in the retro- peritoneum or the posterior pararenal space [27]. CT scan is more accurate than sonography for the diag- nosis of acute pancreatitis and its complications, but sonography is more accurate for the diagnosis of gall- stones [28].

The relative importance of CT scan as a diagnostic method is highlighted by the fact that no current lab- oratory test, including Amylase/Creatinine clearance ratio, serum lipase, serum RN'ase, methalbumin- aemia, is specific for acute pancreatitis [17]. Another advantage of a CT scan is to avoid, in cases of diag- nostic uncertainty, an unjustified operation. The lim- its of CT scanning are, however, the impossibility of differentiating solid necrosis from fluid necrotic col- lections and of predicting those lesions that will sub- side spontaneously and those that will require surgical intervention.

In the past decade the most important change in at- titude towards the treatment of acute necrotizing pan- creatitis has been an increasing interest in early medical supportive care and the expense of early surgery.

The medical approach to acute pancreatitis is largely limited to supportive treatment of haemody- namic, respiratory, renal, and metabolic disorders but since drugs such as glucagon, somatostatine, cime- tidine, aprotinine and atropine, have been proved to be inefficient, there has been a resurgence of interest in the use of peritoneal dialyis [3, 7, 10, 16, 18]. This procedure that removes toxic pancreatic exudate from the peritoneal cavity was first introduced by Wall who noted a dramatic improvement in patients treated for associated renal failure [31]. Further clinical studies demonstrated the efficiency of peritoneal lavage when applied to patients early in the course of acute pancre- atitis, the lavage being carried out with isotonic glu- cose or saline solution [2, 4, 23, 29].

108 F. Bonnet et al.: Acute severe pancreatitis

The nature of the initial aspirated peritoneal fluid is of diagnostic and prognostic importance as demon- strated by Mac-Mahon [12]. Abdominal pain, symp- toms of shock, renal failure and hypocalcaemia usual- ly improve quickly with peritoneal lavage but the re- spiratory state may be transiently worsened by seques- tration of lavage fluid.

Several studies have demonstrated that peritoneal lavage reduces the early mortality of acute pancreati- tis [25, 29]. Stone and Fabian, in a prospective study, noted that 29 out of 36 patients were improved by peritoneal lavage while the condition of 23 non-treat- ed patients worsened, 17 of whom were subsequently treated by peritoneal lavage with good results in 14 [29]. However, whilst peritoneal lavage is efficient for improving the patient's condition in the early phase of the disease, it does not appear to lower the overall mortality rate [20, 29]. Furthermore a recent prospective randomized study fails to document any significant improvement in the early and the overall mortality in patients with severe acute pancreatitis treated by peritoneal lavage [14]. The discrepancy be- tween this present study and the previous reports could be explained by a delay in the institution of the therapy, a difference in the causes of the pancreatitis, or, finally, some difference in the non-specific sup- portive medical treatment, especially the treatment of acute respiratory failure or shock state. This problem is discussed by Raynaert et al. in this issue. They observed that mortality rates decreased in the later years of their study, however, changes in surgical management could also contribute to this improve- ment.

If early peritoneal lavage now replaces early sur- gery, which has been shown to worsen the prognosis [20, 30], the exact role and timing of surgery in acute pancreatitis remains a difficult problem [13, 24]. Even biliary pancreatitis which has been advocated as an in- dication for early laparotomy seems to benefit from initial non-operative management. Ultimately, it seems that the decision to intervene surgically is deter- mined more by the severity of the disease than by its cause. The recurrence of signs of shock after an initial improvement or the appearance of abdominal sepsis are the most frequent events leading to operation. When an operation is considered then a CT scan is of the utmost importance because of its faculty for dem- onstrating the location of any fluid collections [15, 27].

Controversial data are reported concerning the most efficient surgical technique. Total to near total pancreatectomy has been recommended by some authors; but in these studies the severity of pancreati- tis was most evaluated by objective criteria and it is therefore not possible to determine the groups of pa-

tients who could benefit from such a procedure [5, 9, 32]. On the contrary, Ranson reports a 100°70 mortali- ty rate with this procedure [20]. Early cholecystecto- my and exploration of the common bile duct has been recommended by Acosta who found a relationship be- tween the duration of the impaction of a stone in the ampulla and the severity of the pancreatitis [1]. Others supported the use of endoscopic sphincteroto- my [26], but Ranson has again shown that early oper- ation increases morbidity whatever the etiology of pancreatitis [22]. It seems that, whilst cholecystecto- my and exploration of the common bile duct are indi- cated in mild pancreatitis [2, 5, 19], these procedures are not effective and are sometimes technically impos- sible in acute necrotizing pancreatitis.

Pancreatic damage and limited evacuation of ne- crotic pancreatic tissue or abscesses seems to be the least harmful treatment but this often requires numer- ous re-operations for recurrent abscesses or bleeding.

On the basis of all the available evidence we have to conclude that further studies to evaluate the man- agement of acute necrotizing pancreatitis using peri- toneal lavage, CT scanning and limited pancreatic drainage will have to be performed before the ques- tions can be authoritatively answered.

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F. Bonnet et al.: Acute severe pancreatitis 109

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Dr. F, Bonnet D~partement d'Anesth6sie-R6animation H6pital Henri Mondor 51, avenue due Mar6chal de Lattre de Tassigny F-94010 Cr6teil France