NECROTIZING PANCREATITIS - OPERATING FOR LIFE

Infected necrotizing pancreatitis is the most fulminant variety of thi s disease. Colonic involvement and retroperitoneal fasciitis are parti cularly lethal. The reported mortality is up to 50%. The purpose of th is study is to review our combined experience at the Princess Alexandr a Hospital and the Royal Brisbane Hospital, Brisbane, to determine whe ther patient survival was related to a particular etiology, treatment, or complication. all patients treated since 1986 with infected pancre atitis who required surgical necrosectomy and then ventilation in the intensive care unit (ICU) were studied. There were 48 patients so mana ged. The median age of survivors was 52 years, and for those who died it was 64 years (p = 0.001). The etiology was gallstones in 22 and alc oholism in 12. Of the alcoholics, 11 survived and 1 died. Of the patie nts with gallstones, 13 survived and 9 died. There was an overall mort ality of 31%. Survivors were in hospital for a median of 73 days, wher eas deaths occurred after a median of 35 days (p = 0.04). Seven patien ts underwent hemofiltration; five survived, and two died. N-Acetylcyst eine has been used in four patients, of whom three survived and one di ed. The abdomen was left open in 38 patients and kept closed in 10. Al though Ranson's criteria at admission to the ICU did not predict survi val, ti was found that the median APACHE II score in survivors was sig nificantly lower than in those who died (p = 0.025). However the need for colectomy or the finding of retroperitoneal fasciitis in seven pat ients caused a significantly higher mortality, which was not predicted by Ranson's criteria or APACHE II scores (p = 0.007). Death was due t o overwhelming sepsis in most cases, although 47% of patients who died had also suffered major bleeding or fistulas. Nonparametric, box plot analysis shows the following trends: (1) Alcohol was not the most com mon cause of necrotizing pancreatitis, nor did it carry the highest mo rtality. (2) Tissue adjacent to the pancreas progressively necrosed ov er days or weeks. (3) Low initial APACHE II scores were frequently fou nd in patients who ultimately died with colonic necrosis and retroperi toneal fasciitis. (4) Survivors tended to be treated by open laparosto my sooner, have longer periods in hospital, and be significantly young er. In conclusion, patients do best with early, open, repeated surgica l debridement of the retroperitoneum for what appears to be an ongoing process.