FULMINANT ACUTE-PANCREATITIS AND INFECTED NECROSIS - RESULTS OF OPEN MANAGEMENT OF THE ABDOMEN AND PLANNED REOPERATIONS

Background: Controversy still surrounds the management of fulminant ac ute necrotizing pancreatitis. Because mortality rates continue to be h igh, especially in patients with fulminant acute pancreatitis and infe cted necrosis, aggressive surgical techniques, such as open management of the abdomen and ''planned'' reoperations, seem to be justified. St udy Design: From 1988 through 1995, 28 patients with fulminant acute p ancreatitis and infected necrosis were treated with open management of the abdomen followed by planned reoperations at our surgical intensiv e care unit. Results: All patients had infected necrosis with severe c linical deterioration: 12 patients had an Acute Physiology and Chronic Health Evaluation (APACHE) II score greater than or equal to 20 and 1 6 patients had a Simplified Acute Physiology Score (SAPS) greater than or equal to 15. Nineteen patients suffered from severe multiorgan fai lure; the remaining 9 patients needed only ventilatory and inotropic s upport. The mean number of reoperations was 17. In 14 patients, major bleeding occurred; fistula developed in 7. Later, 9 abscesses were dra ined percutaneously. The hospital mortality rate was 39%. Longterm mor bidity in survivors was substantial, especially concerning abdominal-w all defects. Conclusions: Open management of the abdomen followed by p lanned reoperations is an aggressive but reasonably successful surgica l treatment strategy for patients with fulminant acute pancreatitis an d infected necrosis. Morbidity and mortality rates were high, but in t hese critically ill patients, such high rates could be expected. Becau se management and clinical surveillance require specific expertise, ma nagement of these patients is best undertaken in specialized centers. (J Am Coll Surg 1998;187:255-262. (C) 1998 by the American College of Surgeons)