Ulus Travma Acil Cerrahi Derg. 2006; 12(1): 26-34

Akut nekrotizan pankreatit: Otuz sekiz hastanýn tedavi sonuçlarý

Mustafa TÝRELݹ, Atilla YILDIRIM², Cem GÜÇLܲ, Bülent ÇALIK², Burcu DÝLÝÜZ^2
1Celal Bayar Üniversitesi Týp Fakültesi Genel Cerrahi Anabilim Dalý, Manisa, Türkiye
²Department of 2nd. General Surgery SSK Tepecik Training and Research Hospital, Ýzmir, Turkey.

AMAÇ
Bu çalýþmada akut nekrotizan pankreatit nedeniyle cerrahi ve konservatif tedavi uygulanan hastalar deðerlendirildi. GEREÇ VE YÖNTEM Akut nekrotizan pankreatitli 38 hasta (22 erkek, 16 kadýn; ort. yaþ 51.3; daðýlým 16-79) uygulanan tedavi yöntemlerinin sonuçlarý açýsýndan retrospektif olarak incelendi. Konservatif tedavi uygulanan grupta 15, ameliyat edilen grupta ise 23 hasta vardý.
BULGULAR
En sýk (17 hasta) nekrotizan pankreatit nedeni safra taþý idi. Yirmi beþ hastada steril nekroz ve 13 hastada enfekte nekroz olduðu belirlendi. Yirmi beþ steril nekrozlu pankreatit hastasý- nýn 15'ine sadece konservatif tedavi, 10'una ise önce konservatif ve takiben cerrahi tedavi (altýsý þüpheli taný, üçü organ yetersizliði, bir hasta da semptomatik psödokist nedeniyle) uygulandý. Steril nekroz oluþan hastalarda ameliyatta nekrozlu bölge çýkarýldý ve sonra altýsýnda sürekli lavaj, dördünde pasif drenaj yöntemleri uygulandý. Hastalarýmýzda mortalite oraný, her iki grubun toplamýnda %23.7, steril nekrozlu pankreatit grubunda %24.0, enfekte nekrozlu pankreatit grubunda ise %23.1'dir. Mortalite oraný, konservatif tedavi uygulanan hasta grubunda %26.7, ameliyat edilenlerde %21.7 olarak saptandý. Mortalite oraný yönünden gruplar arasýnda istatistiksel olarak anlamlý bir fark bulunmadý (p>0.05). Yaþayan 29 hastanýn 11'inde (%38.0) çeþitli komplikasyonlar görüldü.
SONUÇ
Steril nekrozlu pankreatitin tedavisi tartýþmalýdýr. Öncelikle konservatif tedavi uygulanmalýdýr. Steril nekrozlu pankreatitte ameliyat endikasyonu, yoðun konservatif tedaviye raðmen sepsis veya organ yetmezliði bulgularýnýn devam etmesi ya da þiddetlenmesi durumunda ortaya çýkar. Enfekte nekrozlu pankreatit ise cerrahi yöntemle tedavi edilmelidir. Ameliyat, nekrozun demarkasyon hattý tamamlandýktan sonra gerçekleþtirilmelidir.

Anahtar Kelimeler: Akut nekrotizan pankreatit/mikrobiyoloji/mortalite/terapi; prospektif çalýþma; risk faktörleri; saðkalým oraný.

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Acute necrotizing pancreatitis: the results of the management of 38 patients

Mustafa TÝRELݹ, Atilla YILDIRIM², Cem GÜÇLܲ, Bülent ÇALIK², Burcu DÝLÝÜZ^2
1Department of General Surgery Medicine Faculty of Celal Bayar University, Manisa, Turkey.
²Department of 2nd. General Surgery SSK Tepecik Training and Research Hospital, Ýzmir, Turkey.

BACKGROUND
We evaluated the patients who underwent surgical or nonoperative treatment for acute necrotizing pancreatitis.
METHODS
The study included 38 patients (22 males, 16 females; mean age 51.3 years; range 16 to 79 years) with acute necrotizing pancreatitis. Surgical treatment was performed in 23 patients, while 15 patients were treated conservatively.
RESULTS
Gallstone (in 17 patients) was the most common cause of pancreatitis. Twenty-five patients had sterile necrotizing pancreatitis, while 13 patients had infected necrotizing pancreatitis. Fifteen of the 25 cases with sterile necrosis were treated conservatively. The other 10 patients were initially treated by conservative methods, and were later treated surgically (due to six incorrect diagnosis, three organ failures, and one symptomatic pseudocyst). We applied continuous lavage to six of those patients and conventional drainage to four of them. Mortality rate was 23.7% globally; 24.0% in the sterile necrosis group and 23.1% in the infected necrosis group. Mortality rate was 21.7% in the surgical treatment group, and 26.7% in the conservative treatment group. There were no statistically significant differences between those groups (p>0.05). Eleven of the 29 patients who survived had some complications.
CONCLUSION
The management of sterile pancreatic necrosis is still a matter of debate. Most patients with sterile necrosis can be treated with conservative methods. Indication for surgery in sterile necrosis should be based on persisting or advancing organ complications and sepsis signs despite intensive care therapy. The patients with infected necrosis should be treated surgically. Surgical intervention is best deferred until the demarcation of necrosis is complete.

Keywords: Pancreatitis, acute necrotizing/microbiology/mortality/therapy; prospective studies; risk factors; survival rate.

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