Accurate localization and extraperitoneal drainage of pancreatic abscess

Pancreatic abscess: results of prolonged irrigation of the pancreatic bed after surgery

The mortality from pancreatic abscess may approach 70 per cent and the survivors often require repeated operations to debride the pancreas and to drain recurrent abscesses. We report the results of prolonged irrigation of the pancreatic bed after surgical débridement in 11 patients. Surgery was performed at an average of 17 days (range 8-25 days) after the onset of symptoms. The pancreatic slough was thoroughly debrided and 2-6 large drains were placed in the pancreatic bed. Irrigation with saline or Diaflex solution (2-6 l/day) was started after 2 days and continued for a mean of 25 days (range 5-54 days). There were three deaths (27.3 per cent) after surgery: one of these patients required reoperation and packing for massive postoperative haemorrhage and all three had some evidence of persisting sepsis at autopsy. Prolonged irrigation of the pancreatic bed after surgical débridement may reduce mortality and the need for repeated drainage procedures in patients with pancreatic abscess, but the detection and treatment of persisting sepsis remains the major problem.

Surgical aspects of pancreatic abscess

In a retrospective study of all patients admitted with acute pancreatitis to a single hospital over the 10 year period 1975-1984, 22 patients operated upon for pancreatic abscess complicating acute pancreatitis were identified. The accuracy of the assessment by the surgeon of the extent of the abscess and the results of treatment by either local or wide drainage have been reviewed. The surgeon underestimated the extent of the abscess in 5 of the 22 patients. Four of these five patients were assessed as having a localized abscess presenting in the lesser sac and, in the other, the abscess was thought to be confined to the tail of the pancreas. Local exploration and drainage were performed in 13 patients and resulted in a high morbidity and mortality (54 per cent). Wide exploration was performed in nine patients with only two deaths, despite the greater extent of abscess formation. Improvement in outcome seen in the second 5 year period appears to be due to a more aggressive approach to exploration and drainage. The surgeon must be aware that abscesses in the lesser sac often signify more widespread abscess formation. Without wide exploration of the pancreas, assessment at laparotomy is likely to be unreliable. There appears to be additional benefit from wide drainage, even where abscess formation appears localized.

Pancreatic abscesses

This paper presents the clinical features and problems in the management of 34 patients with pancreatic abscesses. In the majority of patients the abscesses developed following an attack of pancreatitis due to alcohol or gallstones. The abscesses were usually multilocular, and often had spread widely in the retroperitoneal space. Invasion into surrounding viscera or the peritoneal cavity occurred in 12 instances, and eight patients developed major bleeding into the abscess cavity. Obstructive complications (affecting bowel, common bile duct and large veins) occurred in eight patients. Twelve of the 34 patients (35 per cent) died, most deaths being due to failure to control sepsis (seven patients) or to massive bleeding from the abscess cavity (three patients). The mortality of this condition is likely to remain high, but may be reduced by better drainage techniques at the initial exploration. The importance of the infra-mesocolic approach for drainage is emphasized.