Management of complications after operations for acute pancreatitis

[Colon necrosis as a complication of necrotizing pancreatitis]

Necrosis of the colon is a rare but often fatal complication of necrotizing pancreatitis. Among 159 patients with necrotizing pancreatitis who were treated between 1 January 1986 and 31 December 1988, a colonic lesion developed in 10 patients (6.3%). All 10 patients underwent surgery. With regard to the time of occurrence and the extent of the lesion two types could be distinguished: first, extensive, probably ischemic colonic necrosis developed early in the course of the disease, i.e., within the 1st week; second, localized lesions mainly in the region of the left colonic flexure occurred much later and were considered to be a complication related to persistent infection in the remaining pancreatic necroses. The colonic lesions were treated by resection and fecal diversion in 9 patients and by local excision with direct closure and additional diverting colostomy in one patient. Even though the colonic complications could be controlled, only 1 of the 10 patients survived. This can be explained by the fact that all these patients had a severe form of the disease with extensive pancreatic necroses and were in a septic-toxic state with multiple organ failure at the time the colonic lesion occurred.

Debridement and closed cavity irrigation for the treatment of pancreatic necrosis

Pancreatic and peripancreatic debridement combined with a closed cavity system of drainage was used to manage necrotic sequelae of severe acute pancreatitis in 14 patients. Intravenous contrast-enhanced computed tomography, or latterly incremental dynamic computed tomographic angiography, accurately detected and localized necrotic tissue. Operation was delayed where possible to permit demarcation of the necrotic area and the development of a 'capsule' of inflammatory tissue. A retrocolic route of access to the necrotic area was used in nine cases, and purpose-made silicone elastomer tubes with an outside diameter of 20 mm were positioned so that drainage was assisted by gravity when the patient was supine. The cavity was irrigated with saline (initially 2 litres daily), and in the last seven patients Trasylol was included in the irrigation fluid (5 x 10(6) kallidinogenase inactivator (KI) units/litre) for the first postoperative week. Three elderly patients died (mean age 72 years) but all patients aged less than 68 years survived. Planned reoperation was carried out in two patients, but further reoperations were not required in the remaining 11. Drainage tubes were removed when contrast studies showed the cavity to be small and superficial; the median duration of drainage was 28 days. Although sinograms demonstrated fistulae between cavity and small bowel (n = 4) or small bowel and colon (n = 2), no clinical problems resulted and all closed spontaneously. Closed drainage may be as effective as techniques of marsupialization, but avoids the need for frequent relaparotomy.

Results of mobilization and drainage of the pancreas for acute pancreatitis

The surgical treatment of acute pancreatitis remains controversial. Since 1969, we treated 60 patients with acute pancreatitis. In 34 with severe acute pancreatitis who were not responding adequately to intensive medical care, surgical intervention was made by mobilization of the pancreas from retroperitoneal tissue and drainage of the pancreatic bed (M-D procedure). Thirty-four operative cases were classified into 7 edematous, 7 hemorrhagic, and 20 necrotizing. Macroscopic findings of the pancreas did not correlate either to the severity of the acute pancreatitis or to the mortality rate. Eight of 34 who underwent M-D procedure died (23 per cent), but the rate became 14.7 per cent after excluding 3 who died of unrelated causes. These data suggest that the M-D procedure is highly effective in the treatment of early cases of severe acute pancreatitis. There was an associated marked reduction in the mortality rate with the prophylactic use of broad spectrum antibiotics. With M-D procedure, there was a low incidence of late sequelae of pancreatic or peripancreatic abscess.

Colonic complications of acute pancreatitis and pancreatic abscess

Colonic involvement should be suspected in patients with severe acute pancreatitis, especially in the following clinical settings: plain abdominal radiographs suggesting bowel ischemia, colonic obstruction, acute lower gastrointestinal hemorrhage, gram-negative septicemia, enteric bacteria on Gram stain or culture of peritoneal fluid, and feculent abdominal drainage from a previously drained pancreatic abscess. Intraoperatively, the pancreas should be widely drained and the fecal stream diverted. Colonic hemorrhage and nonviable bowel require immediate resection. Broad-spectrum antibiotic administration and vigorous nutritional support also are required in these critically ill patients. Although proximal diversion and pancreatic diversion alone may suffice, colonic resection may be required later for persistent obstruction or fistulization, but in a more elective setting. Colonic anastomoses should be performed only when pancreatic inflammation and associated sepsis have resolved completely.