Techniques and complications of open packing of infected pancreatic necrosis

Open packing of infected pancreatic necrosis has been used in a disease process that is known to have a high mortality rate. From 1982 to 1991, we managed 15 patients with infected pancreatic necrosis with this technique. The cause of the underlying pancreatitis was ethanol in seven patients, gallstones in four, drug induced in two, trauma in one patient and postoperative in one. At hospital admission, the mean number of Ranson's criteria was 4.5 (range of zero to 11). The diagnosis was made by computed tomographic scan in 13 patients, endoscopic retrograde cholangiopancreatography in one patient and clinically in one; eight patients demonstrated air in the pancreas or lesser sac. Operative débridement of the pancreas was performed by way of a midline incision in four patients and a transverse incision in 11 patients. All wounds were left open or closed partially over gauze packing; polyglycolic mesh was used as an adjunct to wound closure to prevent evisceration. Other procedures at initial operation included transverse colectomy (two patients), duodenal diverticulization (one patient), jejunostomy (six patients) and cholecystostomy (four patients). The mean number of subsequent dressing changes in the operating room was five (range of one to 13); subsequent dressing changes were performed in the intensive care unit. Three patients died (the survival rate was 80 percent). The mean period of time in the intensive care unit was 26 days (range of zero to 67 days). Early complications included pulmonary insufficiency in 14 patients, bleeding in four, intestinal fistulas in four and pancreatic fistula in one patient. The most common late complication was incisional hernia, which occurred in seven patients. We conclude that open packing of infected pancreatic necrosis is an effective treatment for this previously lethal condition. However, this treatment is labor intensive and requires a committed team of surgeons, interventional radiologists and critical care personnel. Attention to specific technical aspects of the procedure can minimize complications.