A 15-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 com plications of acute pancreatitis. In this report, a single institution al experience in the surgical management of infected pancreatic necros is during a 15 year period is chronicled. Using open drainage with sch eduled abdominal re-explorations, the overall mortality rate was 15 pe rcent in 71 consecutive patients with infected pancreatic necrosis. In the most recent 25 instances, sequential re-explorations were perform ed until retroperitoneal granulation occurred, at which time the abdom en was closed over lesser sac lavage catheters. Compared with the orig inal 46 patients permitted to heal entirely by secondary intention, pa tients undergoing delayed secondary closure and lavage had a significa nt decrease during the hospitalization period (48.8 versus 30.1 days; p<0.05), without a significant change in the mortality rate. In the mo st 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 t he patients, respectively. Preoperative endoscopic retrograde cholangi opancreatography demonstrated leakage of contrast material from necrot ic pancreatic ducts in seven of eight patients, while postoperative pa ncreatograms revealed abrupt truncation or other abnormalities in 11 o f 13 patients. These observations establish that necrotizing pancreati tis involves pancreatic parenchyma as well as peripancreatic adipose t issue. Open drainage with contingent secondary closure and high volume lavage deserves a place in the management of patients with extensive infected pancreatic necrosis.