title: Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients.
abstract: OBJECTIVE
  To examine the surgical indications and clinical outcomes of a large cohort of patients with necrotizing pancreatitis.
  
  
  BACKGROUND
  Mortality after debridement for necrotizing pancreatitis continues to be inordinately high. The clinical experience with patients who underwent uniform surgical treatment for necrotizing pancreatitis at the Massachusetts General Hospital over a 15-year period is described.
  
  
  METHODS
  Retrospective review of 167 patients with necrotizing pancreatitis who required intervention and were treated with single stage debridement and a closed packing technique. Particular emphasis was placed on the indication for surgery and the presence of infected necrosis. Multiple logistic regression models were used to identify predictors of mortality.
  
  
  RESULTS
  The primary preoperative indication for operation was infected necrosis (51%), but intraoperative cultures proved that 72% of the entire cohort was infected. The rate of reoperation was 12.6%, and 29.9% of patients required percutaneous interventional radiology drainage after initial debridement. Overall operative mortality was 11.4% (19/167), but higher in patients who were operated upon before 28 days (20.3% vs. 5.1%, P = 0.002). Other important predictors of mortality included organ failure > or =3 (OR = 2.4, P = 0.001), postoperative intensive care unit stay > or =6 days (OR = 15.9, P = 0.001), and female gender (OR = 5.41, P = 0.02).
  
  
  CONCLUSIONS
  Open, transperitoneal debridement followed by closed packing and drainage results in the lowest reported mortality and reoperation rates, and provides a standard for comparing other methods of treatment. A negative FNA does not reliably rule out infection. The clinical status of the patients and not proof of infection should determine the need for debridement.
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
authors.forename: J Ruben
authors.initials: JR
authors.lastname: Rodriguez
authors.forename: A Oswaldo
authors.initials: AO
authors.lastname: Razo
authors.forename: Javier
authors.initials: J
authors.lastname: Targarona
authors.forename: Sarah P
authors.initials: SP
authors.lastname: Thayer
authors.forename: David W
authors.initials: DW
authors.lastname: Rattner
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Warshaw
authors.forename: Carlos
authors.initials: C
authors.lastname: Fernández-del Castillo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001419:Bacteria / Q000302:isolation & purification; D001424:Bacterial Infections / Q000150:complications* / Q000401:mortality / Q000601:surgery; D003646:Debridement / Q000379:methods* / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D008875:Middle Aged; D019283:Pancreatitis, Acute Necrotizing / Q000150:complications / Q000401:mortality / Q000601:surgery*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome