Complex treatment of infected necrotizing pancreatitis

: Pancreatic necrosis associated with septic conditions is the leading cause of mortality in acute pancreatitis. Since 1986, 155 patients with infected pancreatic necrosis have been treated. The mean APACHE II score was 18.5 (range 11-32). In all cases, the infected pancreatic necrosis was combined with retroperitoneal abscesses. The surgical treatment was performed on average 18.5 days (range 8-25 days) after the onset of acute pancreatitis. The operative management consisted of wide-ranging necrosectomy in the total affected area, combined with widespread lavage and suction drainage. In 69 of the 155 cases (45%), some other surgical intervention (distal pancreatic resection, splenectomy, cholecystectomy, sphincteroplasty or colon resection) was also performed. Following surgery supportive therapy was applied in all patients, which also consisted orf immunonutrition (glutamine and arginine supplementation) and modification of cytokine production by petoxyfillin and dexamethasone from 1992. TNF and IL-6 serum levels were measured by ELISA and in vitro stimulation of leukocytes were induced by E. coli LPS. Following surgery, continuous lavage and suction drainage were applied for an average of 41.5 days (range 21-90 days), with an average of 9.5 (range 5-20) litres of saline per day. The bacteriologic findings revealed mainly enteral bacteria, but Candida infection was also frequently detected. The incidence of fungal infection was 20%. Thirty-two patients (21%) had to undergo reoperation. The cytokine production capacity (TNF and IL-6) was shown to correlate with the prognosis. As a consequence of pentoxifyllin and dexamethasone therapy, the TNF production generally dropped to the normal level. The overall hospital mortality was 6.4% (10 patients died). In our experience, infected pancreatic necrosis responds well to aggressive surgical treatment, continuous, long-standing lavage and suction drainage, together with supportive therapy consisting of immunonutrition and modification of cytokine production, combined with adequate antibiotic and antifungal medication.