Role of early multisystem organ failure as major risk factor for pancreatic infections and death in severe acute pancreatitis

Background & Aims: Infection of necrosis is considered as principal determinant of outcome in necrotizing pancreatitis and as potential complication after operative treatment of sterile necrosis. In this report a new concept is proposed. Methods: Of 392 patients with necrotizing pancreatitis, 135 patients with operatively treated sterile necrosis were stratified into 3 postoperative entities: secondary pancreatic infections (PIN, group I), pancreatic contaminations (group II), and sterile courses (group III). Ninety-five patients with conservatively treated sterile necrosis (group IV) served as controls. Results: Secondary PIN developed in 64 (47%) patients and contaminations in 37 (27%) patients, whereas 34 (25%) patients remained sterile postoperatively. Secondary PIN and contaminations were both diagnosed after a median of 3 weeks after disease onset. Early/ preoperative multisystem organ failure (MODS) affecting >2 organs was more frequent in group I (35%) than in group II (5%), group III (12%), and group IV (7%) (P <.003); mortality rates were 38%, 3%, 21%, and 7%, respectively (P <.001). Multiple logistic regression identified early/preoperative MODS and extent of intrapancreatic necrosis as major risk factors to develop secondary PIN in operatively treated sterile necrosis. However, irrespective of operative or conservative treatment, only early onset MODS >2 organs proved to be the predominant risk factor for death. Conclusions: Early MODS and extended intrapancreatic necrosis are risk factors for secondary PIN after operative treatment of sterile necrosis. In contrast, the ultimate outcome strongly depends on early and high systemic illness, whereas local pathology and operative procedure seem to be less important.