Eliminated 12 patients required surgical treatment

\* Data expressed in mean ± standard deviation NR: Not Reported

**Table 3.** Outcomes of Patients with Infected Pancreatic Necrosis Receiving Primary Conservative Management

The principle for the indication necrosectomy is shifting from infection-based to organ failureor complication-based. While conservative-first approach is a reasonable approach for the management of infected pancreatic necrosis, it is important to recognize those patients might require necrosectomy later as a step-up therapy at an appropriate time. [76] Indications for necrosectomy include nonresponse to conservative treatment and development of local complications such as bleeding and colonic perforation. Extend and infection of pancreatic necrosis correlated with the development of organ failure and mortality in acute pancreatitis. [81,82] Large amount of thick necrotic debris at difficult-to-drain locations and resistant organisms could be the reasons for failure of conservative therapy. Two studies sought to identify the predictive factors for the need for early surgery. Zerem et al showed that Ranson, Glasgow, and APACHE II scores, CTSI, and C-reactive protein could predict the need for surgery in their patients, but the 95% confidence interval showed that none of the factors were found to be a significant predictor. [73] Garg et al showed that high APACHE II score and serum creatinine level were predictive of mortality. [66] Unfortunately, no predictive factor that could guide a clinician to move towards early surgical intervention was identified in the currently available studies.

#### **13. Conclusion**

patients required necrosectomy or additional surgery for complications (95% confidence

Conservative treatment for infected pancreatic necrosis should include intensive care with full organ support, use of effective antimicrobials, and aggressive nutritional support. Percutane‐ ous drainage, despite it is a form of intervention and not truly conservative, has also been considered a part of conservative treatment because it does not involve surgery or formal

> **Successful conservative treatment (%)**

⌘Freeny (1998) [77] 34 100 (34/34) 47.1 (16/34) 52.9 (18/34) 45 11.8 (4/34) Runzi (2005) [68] 28 18.75 (3/16) # 50 (14/28) 42.9 (12/28) 54 ± 10 \* 14.3 (4/28) Song (2006) [72] 19 NR 78.9 (15/19) 21.1 (4/19) 70 5.3 (1/19)

Lee (2007) [67] 31 67.7 (21/31) 71 (22/31) 12.9 (4/31) 37.7 ± 28.5 \* 3.2 (1/31)

Garg (2010) [66] 77 45.45 (35.77) 54.4 (42/77) 23.4 (18/77) 26.5 28.6 (22/77)

Zerem (2011) [73] 86 80.2 (69/86) 84.9 (73/86) 12.8 (11/86) 13 9.3 (8/86) Gluck (2012) [74] 20 100 (20/20) 70 (14/20) 15 (3/20) 54 15 (3/20)

**Table 3.** Outcomes of Patients with Infected Pancreatic Necrosis Receiving Primary Conservative Management

The principle for the indication necrosectomy is shifting from infection-based to organ failureor complication-based. While conservative-first approach is a reasonable approach for the management of infected pancreatic necrosis, it is important to recognize those patients might require necrosectomy later as a step-up therapy at an appropriate time. [76] Indications for necrosectomy include nonresponse to conservative treatment and development of local

**Need for surgery**

**Median/ mean hospital stay (days)**

**Mortality (%)**

**(%)**

30 100 (30/30) 63.3 (19/30) 33.3 (10/30) 24 16.6 (5/30)

80 100 (80/80) 47.5 (38/80) 20 (16/80) 51 33.8 (27/80)

13 100 (13/13) 46.2 (6/13) 53.8 (7/13) 33 7.7 (1/13)

43 95.3 (41/43) 34.9 (15/43) 60.4 (26/43) 50 18.6 (8/43)

20 50 (10/20) 65 (13/20) 30 (6/20) NR 5 (1/20)

⌘ Studies reported the results of only those patients who underwent percutaneous drainage for the management of

interval, 15%–37%).

196 Acute and Chronic Pancreatitis

**Reference (year) No. of patients**

⌘Navalho (2006)

⌘Bruennler (2008)

⌘Mortele (2009)

Van Santvoort (2010) [54]

Alsfasser (2012)

infected pancreatic necrosis
