MANAGEMENT OF INFECTED PANCREATIC FLUID COLLECTIONS

Percutaneous drainage of pancreatic collections has recently been advo cated as a means of diagnosis of bacterial contamination, for temporiz ing unstable patients, and as definitive treatment in itself In order to assess its efficacy, the role of percutaneous drainage of infected pancreatic fluid collections was retrospectively reviewed by a single surgical practice. Seventeen patients were treated over a 5-year perio d from 1987 to 1992. All patients admitted or referred with a diagnosi s of infected peripancreatic fluid collection were included in the rev iew. The group consisted of eleven males and six females; mean age was 55.2 years (range 28 to 70). Patients were stratified into one of two groups based on initial treatment modality. Group A consisted of eigh t patients treated initially with percutaneous drainage as presumed de finitive management. Eight patients in Group B were treated initially with surgical debridement and drainage. APACHE II scores on admission were 5.62 +/- 3.66 for Group A and 9.12 +/- 3.87 for Group B (N.S.). M ean hospital stay was 100 days (range 13-311) for Group A and 71 (rang e 25-149) for Group B (N.S.). Despite initial percutaneous drainage, s ix of eight (75%) patients in Group A required operative debridement b ecause of clinical deterioration. APACHE II scores in this subset went from 6.83 +/- 3.43 to 9.83 +/- 5.04 (N.S.) despite a total of 18 preo perative percutaneous procedures (2.25 per patient; range 1-7). The nu mber of complications for this group totaled 15. Five of the six patie nts with positive cultures from their initial aspiration failed percut aneous drainage. Patients in Group A required an average of 1.44 opera tive debridements per patient (range 1-3); those in Group B, who were treated initially with surgical debridement, averaged 2.0 per patient (range 1-7) (N.S.). Five patients in Group A suffered a total of 15 co mplications. There was one mortality in this group (63% morbidity, 13% mortality). Seven patients in Group B suffered a total of 17 complica tions, with two deaths occuring in this group (88% morbidity, 25% mort ality) (N.S.). Based on our experience, percutaneous drainage of infec ted pancreatic collections should not be used as initial therapy. This approach leads to a trend of clinical deterioration and higher mortal ity, not to stabilization or improvement There is also a trend toward prolonged hospital stay in the group treated initially with percutaneo us drainage. Operative debridement was ultimately required in the majo rity of these patients. Documentation of bacterial contamination was a strong predictor of the need for eventual surgical debridement. An ag gressive approach of early surgical debridement for patients presentin g with infected pancreatic fluids collections is recommended.