Journal of the American College of Surgeons
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Controversy still surrounds the management of fulminant acute necrotizing pancreatitis. Because mortality rates continue to be high, especially in patients with fulminant acute pancreatitis and infected necrosis, aggressive surgical techniques, such as open management of the abdomen and "planned" reoperations, seem to be justified. ⋯ Open management of the abdomen followed by planned reoperations is an aggressive but reasonably successful surgical treatment strategy for patients with fulminant acute pancreatitis and infected necrosis. Morbidity and mortality rates were high, but in these critically ill patients, such high rates could be expected. Because management and clinical surveillance require specific expertise, management of these patients is best undertaken in specialized centers.
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Operating for bleeding gastric ulcer remains controversial. Gastric resection bears a higher surgical risk while limited operation may result in more postoperative hemorrhage. There has been little discussion of effective risk assessment of patients. The aim of this study is to define surgical risk by using the APACHE II scoring system, and to determine optimal management. ⋯ APACHE II score is a useful tool for assessing risk in patients with bleeding gastric ulcer. The mortality is minimal in those with a score <15, and PGR can be performed with low risk. Although high-risk patients have dreadful outcomes, limited operation cannot improve them if postoperative hemorrhage occurs. Decision making in emergency operation for such patients should be based on the ulcer conditions and the patient's hemodynamic status.