Management of infected pancreatic necrosis by open drainage

Twenty-eight consecutive patients with infected pancreatic necrosis were managed by extensive unroofing of the superior retroperitoneum, blunt pancreatic sequestrectomy, laparotomy pad packing of the lesser sac over a layer of Adaptic gauze, and scheduled re-explorations at intervals of 2-3 days (open drainage). Wounds were permitted to heal by secondary intention. All patients were maintained on intravenous hyperalimentation. Three of the 28 patients died (11%); none died of sepsis. Procedure-specific complications included: pancreatic fistula (10 patients), incisional hernia (8 patients), persistent functional gastric outlet obstruction (2 patients), retroperitoneal venous hemorrhage (2 patients), and intestinal fistula (1 patient). Limited initial experience with dynamic pancreatography and serial monitoring of acute phase reactants as indicators of pancreatic necrosis is promising. Compared with historic controls, open drainage of infected pancreatic necrosis represents a significant advance over more conventional surgical approaches. Controlled studies and more widespread experience are necessary for further evaluation of this procedure.