Necrosectomy and laparostomy--a combined therapeutic concept in acute necrotising pancreatitis.
OBJECTIVE
To present our experience with laparostomy and necrosectomy in the treatment of acute necrotising pancreatitis, and to show how refinements in our treatment regimen improved mortality over the years despite no reduction in the severity of the disease.


METHODS
Retrospective study.


METHODS
University hospital, Austria.


METHODS
125 patients treated by laparostomy/necrosectomy with repeated revisions during the period January 1983 to December 1991.


METHODS
Laparostomy, blunt necrosectomy, operative lavage, and open drainage.


METHODS
Mortality and morbidity.


RESULTS
The severity of disease was assessed by the APACHE II score (median 15, range 4-30). In 106 of the 125 patients (85%) the necrotic pancreatic tissue was infected. Patients were operated on if they deteriorated clinically or if organ failure was suspected. A change in the protocol from revisions on demand (1983/4) to planned re-exploration at 48 hour intervals (1985/8) was associated with a reduction in mortality from 53% (16/30) to 28% (20/72). This was further reduced in 1989/91 to 17% (4/23) when a protocol of revisions planned for individual patients was introduced (p = 0.02). The incidence of gastrointestinal fistulas during the three periods was 6/30 (20%); 24/72 (33%); and 1/23 (4%); (p = 0.022), whereas that of intraabdominal bleeding remained much the same (7/23, 23%; 13/72, 18%; and 4/23, 17%; p = 0.56). The median (range) APACHE II scores for the three periods were 12 (4-27), 15 (5-30), and 14 (4-25).


CONCLUSIONS
By continual revision of our protocol, together with accompanying improvements in intensive care, our mortality decreased significantly during the nine year period.
Függer
R
R
Chirurgische Klinik, University of Vienna, Austria.
Götzinger
P
P
Sautner
T
T
Mittlböck
M
M
Rogy
M
M
Adamer
K
K
Fritsch
A
A
D000208:Acute Disease; D004322:Drainage; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology; D006801:Humans; D007412:Intestinal Fistula / Q000209:etiology; D008297:Male; D008875:Middle Aged; D009336:Necrosis / Q000473:pathology / Q000601:surgery*; D010195:Pancreatitis / Q000473:pathology* / Q000601:surgery; D011183:Postoperative Complications; D012086:Reoperation; D012720:Severity of Illness Index; D013530:Surgical Wound Infection / Q000628:therapy