Debridement and Closed Packing for Sterile or Infected Necrotizing Pancreatitis (original) (raw)

Objective-To examine the surgical indications and clinical outcomes of a large cohort of patients with necrotizing pancreatitis. Summary Background Data-Mortality after debridement for necrotizing pancreatitis continues to be inordinately high. The clinical experience with patients who underwent uniform surgical treatment for necrotizing pancreatitis at the Massachusetts General Hospital over a 15year period is described. Methods-Retrospective review of 167 patients with necrotizing pancreatitis who required intervention and were treated with single stage debridement and a closed packing technique. Particular emphasis was placed on the indication for surgery and the presence of infected necrosis. Multiple logistic regression models were used to identify predictors of mortality. Results-The primary preoperative indication for operation was infected necrosis (51%), but intraoperative cultures proved that 72% of the entire cohort was infected. The rate of reoperation was 12.6%, and 29.9% of patients required percutaneous interventional radiology drainage after initial debridement. Overall operative mortality was 11.4% (19/167), but higher in patients who were operated upon before 28 days (20.3% vs. 5.1%, P = 0.002). Other important predictors of mortality included organ failure ≥3 (OR = 2.4, P = 0.001), postoperative intensive care unit stay ≥6 days (OR = 15.9, P = 0.001), and female gender (OR = 5.41, P = 0.02). Conclusions-Open, transperitoneal debridement followed by closed packing and drainage results in the lowest reported mortality and reoperation rates, and provides a standard for comparing other methods of treatment. A negative FNA does not reliably rule out infection. The clinical status of the patients and not proof of infection should determine the need for debridement. Necrosis of the pancreas and/or peripancreatic tissues after an attack of acute pancreatitis develops in approximately 10% to 20% of patients, and their management continues to present a challenge. 1 As contemporary literature has favored nonoperative management in patients in whom infected necrosis cannot be proven, infection is said to be the only absolute indication, in effect, the sine qua non, for operative debridement. 2-4 In those patients that do undergo surgery for debridement, mortality continues to be inordinately high, 5,6 but significantly higher in those with infected necrosis compared with sterile necrosis. Since 1980, we have adopted a uniform surgical approach to postpancreatitis necrosis, comprising