Fulminant acute pancreatitis and infected necrosis: Results of open management of the abdomen and "planned" reoperations

Background: Controversy still surrounds the management of fulminant acute necrotizing pancreatitis. Because mortality rates continue to be high, especially in patients with fulminant acute pancreatitis and infected necrosis, aggressive surgical techniques, such as open management of the abdomen and "planned" reoperations, seem to be justified. Study Design: From 1988 through 1995, 28 patients with fulminant acute pancreatitis and infected necrosis were treated with open management of the abdomen followed by planned reoperations at our surgical intensive care unit. Results: All patients had infected necrosis with severe clinical deterioration: 12 patients had an Acute Physiology and Chronic Health Evaluation (APACHE) II score greater than or equal to 20 and 16 patients had a Simplified Acute Physiology Score (SAPS) greater than or equal to 15. Nineteen patients suffered from severe multiorgan failure; the remaining 9 patients needed only ventilatory and inotropic support. The mean number of reoperations was 17. In 14 patients, major bleeding occurred; fistula developed in 7. Later, 9 abscesses were drained percutaneously. The hospital mortality rate was 39%. Longterm morbidity in survivors was substantial, especially concerning abdominal-wall defects. Conclusions: Open management of the abdomen followed by planned reoperations is an aggressive but reasonably successful surgical treatment strategy for patients with fulminant acute pancreatitis and infected necrosis. Morbidity and mortality rates were high, but in these critically ill patients, such high rates could be expected. Because management and clinical surveillance require specific expertise, management 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)