Surgical intervention in acute necrotizing pancreatitis

Thirty-eight patients with acute pancreatitis were treated with an operation that included cholecystostomy, gastrostomy, feeding jejunostomy, and sump drainage of the peripancreatic lesser sac. Of eleven patients judged to be dying of fulminant pancreatitis in the first forty-eight hours of treatment, nine improved immediately and seven survived. Of eighteen patients who underwent operation because of persistent or increased signs of inflammation two weeks after admission, seven had an immediate favorable response, mainly due to drainage of abscesses, necrotic pancreas, or pseudocysts, and twelve survived. Nine patients with pancreatitis of lesser severity received no apparent benefit from the operation. Gastrostomy and jejunostomy were used for prolonged treatment of intestinal dysfunction in nine patients. In six patients the cholecystostomy helped to control bacterial cholangitis. In seven patients the peripancreatic sumps provided tracts for the late drainage of abscesses, pancreatic fistulas, and sloughed pancreas. The major problem after surgery was the development of intra-abdominal abscesses in sixteen patients. Of the thirteen deaths, ten were directly related to these abscesses. An aggressive approach to re-exploration and drainage of late pancreatic abscesses in patients with necrotizing pancreatitis should improve still further the survival rate of patients. The survival of patients with severe pancreatitis resistant to standard medical measures appears to be improved by this operative approach.