Internal Drainage of Infected Pancreatic Necrosis: A Fail-Safe Alternative to Percutaneous Catheter Drainage

Abstract

Necrosectomy and external drainage has been the traditional surgical treatment for infected pancreatic necrosis (IPN) following acute pancreatitis. It is a highly invasive and high risk procedure in an already compromised individual and demands multiple trips to the operating room for subsequent debridement. Recent evidence suggests that minimally invasive procedures, including surgical video-assisted retroperitoneal debridement and percutaneous catheter drainage (PCD) can often “take the heat out of the fire” and thereby delay or even avoid surgery, but these procedures sometimes fail and surgical intervention needs to be undertaken. In order to avoid multiple surgical procedures we decided to drain the IPN internally into the stomach. To ascertain the efficacy and safety of open necrosectomy and internal drainage into the stomach as a feasible alternative in patients with IPN. We conducted a prospective study of the results of open surgical necrosectomy and internal drainage performed on patients with IPN from March 2012 to February 2019. This was a record based qualitative study. The patients were initially managed in the intensive care unit (ICU) with goal-directed therapy and organ support where indicated. All patients with IPN requiring PCD or surgical intervention were included in this study. A total of 44 patients with acute necrotizing pancreatitis who underwent either PCD or surgical drainage were included in the study. Of the 44 patients, 16 (36.4%) were treated with open transgastric debridement and internal drainage into the stomach for IPN. The mean age of this subgroup of patients was 51.3 ± 11.1 years, the most common etiology of the pancreatitis was alcoholic, the mean acute physiology and chronic health (APACHE II) score of these patients was 15.9 ± 4.72, and the mean bedside index of severity in acute pancreatitis (BISAP) score was 4.92 ± 0.11. On contrast enhanced computed tomography (CECT) scan of the abdomen, 93.8% of the patients had >50% necrosis, with a mean CT severity index (CTSI) of 9.3 ± 0.7. The mean operating time was 137 ± 42.4 minutes, with a mean blood loss of 225.4 ± 50.5 ml. Two patients required reoperation because of persistence of necrosum and signs of collection on repeat CT, and there were two mortalities. None of the patients had any late complications related to the surgery and the procedure was successful in 91%. Internal drainage into the stomach in IPN is a feasible and relatively safe procedure when indicated. It is more effective in avoiding repeated surgical procedures when compared to external drainage.