Necrotizing pancreatitis: contemporary analysis of 99 consecutive cases

Pancreatic surgery

Over the past year considerable progress has been made in the field of pancreatic surgery. Innovative diagnostic techniques continue to improve the preoperative staging of pancreatic cancer. For patients with cancer and biliary obstruction, preoperative biliary stenting appears to increase the incidence of wound infection after pancreatoduodenectomy but has no effect on other perioperative complications. New information about the molecular biology of pancreatic cancer may begin to influence the surgical approach to the disease. More cases of intraductal papillary mucinous neoplasms are being diagnosed and studied. The impact of adjuvant chemotherapy and chemoradiation on survival has been more clearly defined in a large, randomized trial. In patients with sterile acute necrotizing pancreatitis, conservative nonsurgical management has continued to produce favorable results. For chronic pancreatitis, surgery appears to diminish both chronic pain and recurrent episodes of acute pain.

Pancreatic sepsis: prevention and therapy

Except for a minority of early fatalities, most deaths in acute pancreatitis occur after the first 7 to 10 days due to infective complications, particularly infected necrosis. Hence, preventing this risk factor seems to represent a major step forward in the clinical management of severe pancreatitis. Consequently, antibiotics emerged as a cornerstone of the treatment of severe acute pancreatitis. The duration of such treatment, the route of administration and the substance(s) of choice need to be carefully selected. Surgical debridement is the treatment of choice of infected necrosis, while percutaneous drainage is successful in some patients.

Débridement and closed packing for the treatment of necrotizing pancreatitis

OBJECTIVE

To evaluate the results of débridement and closed packing for necrotizing pancreatitis and to determine the optimal timing of surgical intervention based on patient outcomes.

METHODS

Between February 1990 and November 1996, 64 consecutive patients with necrotizing pancreatitis were treated with necrosectomy followed by closed packing of the cavity with stuffed Penrose and closed suction drains. The mean APACHE II score immediately before surgery was 9, and 31% of the patients had organ failure. Patients were stratified with an outcome score based on death and major complications; this was correlated with the timing of surgical intervention. The data were then subjected to cut-point analysis by sequential group comparison.

RESULTS

Patients underwent surgery a median of 31 days after diagnosis. Fifty-six percent had infected necrosis. The mortality rate was 6.2% and was no different in infected or sterile necrosis. Eleven patients required a second surgical procedure and 13 required percutaneous drainage; a single surgical procedure sufficed in 69%. Enteric fistulae occurred in 16% of patients. The mean hospital stay after surgery was 41 days, and the interval until return to regular activities was 147 days. A significant negative correlation between duration of pancreatitis and outcome scores was found, and sequential group comparison demonstrated that the change point at which significantly better outcomes were encountered was day 27.

CONCLUSION

Débridement of pancreatic necrosis followed by closed packing and drainage is accomplished with a low mortality rate and reduced rates of complications and second surgical procedures. Although intervention is best deferred until the demarcation of necrosis is complete, delay beyond the fourth week confers no additional advantage.