Infected Necrosis in Severe Pancreatitis - Combined Nonsurgical Multi-Drainage with Directed Transabdominal High-Volume Lavage in Critically Ill Patients

Background: Infection of pancreatic necrosis is a life-threatening
complication during the course of acute pancreatitis. In critically
ill patients, surgical or extended endoscopic interventions are
associated with high morbidity and mortality. Minimally invasive
procedures on the other hand are often insufficient in patients
suffering from large necrotic areas containing solid or purulent
material. We present a strategy combining percutaneous and
transgastric drainage with continuous high-volume lavage for
treatment of extended necroses and liquid collections in a series
of patients with severe acute pancreatitis. Patients and Methods:
Seven consecutive patients with severe acute pancreatitis and large
confluent infected pancreatic necrosis were enrolled. In all cases,
the first therapeutic procedure was placement of a CT-guided
drainage catheter into the fluid collection surrounding
peripancreatic necrosis. Thereafter, a second endosonographically
guided drainage was inserted via the gastric or the duodenal wall.
After communication between the separate drains had been proven, an
external to internal directed high-volume lavage with a daily
volume of 500 ml up to 2,000 ml was started. Results: In all
patients, pancreatic necrosis/liquid collections could be resolved
completely by the presented regime. No patient died in the course
of our study. After initiation of the directed high-volume lavage,
there was a significant clinical improvement in all patients.
Double drainage was performed for a median of 101 days, high-volume
lavage for a median of 41 days. Several endoscopic interventions
for stent replacement were required (median 8). Complications such
as bleeding or perforation could be managed endoscopically, and no
subsequent surgical therapy was necessary. All patients could be
dismissed from the hospital after a median duration of 78 days.
Conclusion: This approach of combined percutaneous/endoscopic
drainage with high-volume lavage shows promising results in
critically ill patients with extended infected pancreatic necrosis
and high risk of surgical intervention. Neither surgical nor
endoscopic necrosectomy was necessary in any of our patients.
Copyright (C) 2009 S. Karger AG, Basel and IAP