P20 – Pancreatitis Managed by an Acute Care Surgery Service: Etiology, Resource Utilization, and Outcomes

Author(s):
Arek Wiktor, Kathleen To, Andrew Rosenberg, Lena Napolitano, University of Michigan Health System

Background: The management of acute pancreatitis (AP) has evolved substantially. Necrotizing pancreatitis (NP) develops in 15-20% of AP, with secondary infection carrying an 8-39% mortality risk and risk for multidrug resistant bacteria (MDR). The randomized trial comparing step-up to open necrosectomy reported mortality rates of 19% vs. 16% (1). Pancreatitis managed by an acute care surgery service (ACS), has not been fully examined.

Hypothesis: AP complicated by NP or MDR infection results in increased resource utilization and worse outcomes.

Methods: Retrospective review of all adult (≥ 18 years old) ACS admissions from 11/2007- 3/2012, with AP (ICD-9 code 577.0). Clinical characteristics, AP etiology, number/type of procedures performed, hospital and ICU length of stay (LOS), ventilator days, microbiology, disposition and mortality were examined.

Results: 148 ACS patients had 169 admissions for AP (mean age 52 years, 43.9% male); hospital LOS was 15.5 days (±19.39), and all-cause mortality was 3.3% (2 NP, 3 non-NP). Most AP was from gallstone pancreatitis (54.4% of admissions, 58.8% of patients). 141 (83.4%) admissions resulted in home discharge, 36 (21.3%) required home health care. NP was diagnosed in 38 (25.7%) of patients; 52 (30.8%) of admissions. Readmissions were significantly greater for NP patients compared to those without [14 (36.8%) vs. 4 (3.6%) (p<0.001)]. NP patients had longer hospital LOS [26.7 ±14.4 vs. 10.6 ± 24.4 days (p<0.001)], and ICU LOS [4.1 ±7.4 vs. 1.5 ±7.1 days (p=0.03)]; but no difference in ventilator days [1.44 ±3.9 vs. 1.09 ±5.3 (p=0.67), respectively]. Sterile necrosis was diagnosed in 13 (25%) of NP admissions. Patients with infected NP required: open necrosectomy 18 (47.4%), percutaneous drainage 6 (15.8%), and cystgastrostomy 3 (7.9%). MDR pathogens were present in 26 (66%) of total isolates, 21 (80%) of patients with infected NP. MDR infection was associated with increased hospital LOS [34.3 ±29.6 vs. 19.1 ±15 days (p=.02)]. Neither infected NP nor MDR were associated with discharge disposition (p=0.30).

Conclusions: NP poses an increased burden on inpatient health care resources by increased LOS, readmission rates, and incidence of MDR infections, but was not associated with increased mortality. Management of NP by an ACS service was associated with decreased mortality compared to published studies.
1.Van Santvoort HC et al. N Engl J Med. 2010 Apr 22;362(16):1491-502.