Planned staged reoperative necrosectomy using an abdominal zipper in the treatment of necrotizing pancreatitis.
OBJECTIVE
The optimal operative treatment for severe necrotizing pancreatitis (SNP) still remains controversial. This article describes the operative approach with a planned staged necrosectomy using the "zipper" technique.


METHODS
Between 1996 and 2000, 35 patients with SNP were treated with this approach. The patient demographics, etiology and severity of SNP, hospital course, and outcome were recorded and comparisons of several parameters were made between the patients who survived and those who died.


RESULTS
Hospital mortality was 34%. A total of 16 fistulae developed in 11 patients (31%), recurrent intra-abdominal abscesses in 4 (11%), and hemorrhaging in 5 (14%). The patients who died compared with those who survived had a higher Acute Physiology and Chronic Health Evaluation (APACHE)-II score on admission (14.5 vs 9, P < 0.001), extrapancreatic extension of necrosis more often (100% vs 65%, P = 0.02), and developed postoperative hemorrhaging more often (33% vs 4%, P = 0.038). A multivariate logistic analysis revealed an APACHE-II score of > 13 on admission (P = 0.018) and an extension of necrosis behind both paracolic gutters (P < 0.001) to both be prognostic factors for mortality.


CONCLUSIONS
Severe necrotizing pancreatitis still carries significant morbidity and mortality. This surgical approach facilitates the removal of all devitalized tissue and seems to decrease the incidence of recurrent intra-abdominal infection requiring reoperation. An APACHE-II score of > or = 13 and an extension of necrosis behind both paracolic gutters was thus found to signify a worse outcome.
Radenkovic
Dejan V
DV
Center of Emergency Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, 2 Pasterova Street, 11000, Belgrade, Serbia and Montenegro.
Bajec
Djordje D
DD
Tsiotos
Gregory G
GG
Karamarkovic
Aleksandar R
AR
Milic
Natasa M
NM
Stefanovic
Branislav D
BD
Bumbasirevic
Vesna
V
Gregoric
Palve M
PM
Masulovic
Dragan
D
Milicevic
Miroslav M
MM
D018806:APACHE; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D003287:Contrast Media; D003646:Debridement / Q000379:methods*; D004630:Emergencies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D015999:Multivariate Analysis; D010180:Pancreatectomy / Q000379:methods*; D010186:Pancreatic Function Tests; D019283:Pancreatitis, Acute Necrotizing / Q000000981:diagnostic imaging / Q000401:mortality* / Q000601:surgery*; D011183:Postoperative Complications / Q000401:mortality; D011336:Probability; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed
D003287:Contrast Media