NECROSECTOMY AND LAPAROSTOMY - A COMBINED THERAPEUTIC CONCEPT IN ACUTE NECROTIZING PANCREATITIS

Objective: To present our experience with laparostomy and necrosectomy in the treatment of acute necrotising pancreatitis, and to show how r efinements in our treatment regimen improved mortality over the years despite no reduction in the severity of the disease. Design: Retrospec tive study. Setting: University hospital, Austria. Subjects: 125 patie nts treated by laparostomy/necrosectomy with repeated revisions during the period January 1983 to December 1991. Interventions: Laparostomy, blunt necrosectomy, operative lavage, and open drainage. Main outcome measures: Mortality and morbidity. Results: The severity of disease w as assessed by the APACHE II score (median 15, range 4-30). In 106 of the 125 patients (85%) the necrotic pancreatic tissue was infected. Pa tients were operated on if they deteriorated clinically or if organ fa ilure was suspected. A change in the protocol from revisions on demand (1983/4) to planned re-exploration at 48 hour intervals (1985/8) was associated with a reduction in mortality from 53% (16/30) to 28% (20/7 2). This was further reduced in 1989/91 to 17% (4/23) when a protocol of revisions planned for individual patients was introduced (p = 0.02) . The incidence of gastrointestinal fistulas during the three periods was 6/30 (20%); 24/72 (33%); and 1/23 (4%); (p = 0.022), whereas that of intraabdominal bleeding remained much the same (7/23, 23%; 13/72, 1 8%; and 4/23, 17%; p = 0.56). The median (range) APACHE II scores for the three periods were 12 (4-27), 15 (5-30), and 14 (4-25). Conclusion : By continual revision of our protocol, together with accompanying im provements in intensive care, our mortality decreased significantly du ring the nine year period.