Delayed Necrosectomy Improves Outcome in Severe Necrotising Pancreatitis

Aim: Current practice of early necrosectomy in cases of infected pancreatic necrosis is associated with 30–35% mortality. The aim of our study was to determine outcome where pancreatic necrosectomy (PN) is delayed.

Methods: We prospectively assessed a policy of delayed PN in patients with pancreatic necrosis over a 4.5-year period. Surgery was preceded by intensive management, radiological drainage of peri-pancreatic collections and antimicrobial therapy where indicated.

Results: Between Jan-1999 and May-2004, of 207 patients admitted with acute pancreatitis, 25(12%) were predicted severe via Modified Glasgow Criteria. 32 patients subsequently developed severe pancreatitis requiring radiological drainage of a peri-pancreatic collection, confirmed infective in 20(63%). 26(81%) patients underwent delayed PN (mean of 55 days from onset of symptoms). Mean APACHE-II score of 10 was recorded for patients when most unwell, while the mean pre-operative APACHE-II score was 5. No patient required further pancreatic debridement or developed an enteric fistula. No mortality occurred amongst patients managed conservatively with radiological drainage; 2 deaths (6%) occurred in the PN-group.

Conclusions: Early necrosectomy for pancreatic necrosis is technically difficult, frequently repeated and associated with significant post-operative complications. Our results demonstrate that intensive conservative management with radiological peri-pancreatic drainage and delayed PN improves morbidity and mortality.