A fifteen year experience with open drainage for infected pancreatic necrosis

Advances in the understanding of the pathophysiologic factors of acute pancreatitis, combined with several recent technologic breakthroughs, have led to the establishment of infected pancreatic necrosis as the most common, the most severe and the most lethal of the infectious complications of acute pancreatitis. In this report, a single institutional experience in the surgical management of infected pancreatic necrosis during a 15 year period is chronicled. Using open drainage with scheduled abdominal re-explorations, the overall mortality rate was 15 percent in 71 consecutive patients with infected pancreatic necrosis. In the most recent 25 instances, sequential re-explorations were performed until retroperitoneal granulation occurred, at which time the abdomen was closed over lesser sac lavage catheters. Compared with the original 46 patients permitted to heal entirely by secondary intention, patients undergoing delayed secondary closure and lavage had a significant decrease during the hospitalization period (48.8 versus 30.1 days; p < 0.05), without a significant change in the mortality rate. In the most recent patients, dynamic pancreatography and fine needle aspiration bacteriologic factors were accurate in the preoperative prediction of pancreatic necrosis and microbial infection in 95 and 97 percent of the patients, respectively. Preoperative endoscopic retrograde cholangiopancreatography demonstrated leakage of contrast material from necrotic pancreatic ducts in seven of eight patients, while postoperative pancreatograms revealed abrupt truncation or other abnormalities in 11 of 13 patients. These observations establish that necrotizing pancreatitis involves pancreatic parenchyma as well as peripancreatic adipose tissue. Open drainage with contingent secondary closure and high volume lavage deserves a place in the management of patients with extensive infected pancreatic necrosis.