[Reoperation in necrotizing acute pancreatitis: evaluation of physiopathology and surgical treatment]

We reviewed our experience of PAN cases operated for complications after a first laparotomy over the period 1992-1994. Over 29 PAN cases, 7 (24%) had been submitted to a second laparotomy or more. Total mortality rate of PAN was 10.3%, while mortality rate of relaparotomy was 14.2%. Haemorrhage and intra-abdominal sepsis were the main cause of relaparotomy (42.8% of the re-operations in both cases). Abdominal wall abscesses (14%) were treated locally; enteric or pancreatic fistulas (34%) were successful treated by drugs, such as somatostatin and octreotide, and / or by total parenteral nutrition. The main diagnostic tools to evaluate clinical course of the patients were computed tomography scan, that seems to gain serial staging of the necrosis and the septic collections. Arteriography is necessary to identify the bleeding source and to perform temporary embolization in the massive arterial haemorrhage before surgical treatment. Moreover, we need radiological exploration to explain fistulas pathways. According to circumstances, we can perform surgically the definitive hemostasis, the pancreatojejunostomy in pancreatic fistulas, and the digestive reconstruction in enteric fistulas. At all events the debridement of necrosis and septic collection is necessary. Up to date, there are not prognostic differences between "closed laparotomy" and "open laparotomy", and we think that the choice is determined only by individual believing of the surgeon.