Aim: Pancreatic necrosis associated with septic conditions is the leading cause of mortality in acute pancreatitis. Activated leukocytes and cytokines have important roles in the multisystem involvement during acute pancreatitis. Patients and methods: Since 1986, 191 patients with infected pancreatic necrosis have been treated. The mean APACHE II score was 18.5 (range 11-32). The surgical treatment was performed on average 18.5 days (range 8-25 days) after the onset of acute pancreatitis. The operative management consisted of wideranging necrosectomy in the total affected area, combined with widespread lavage and suction drainage. In 88 of the 191 cases (46%), some other surgical intervention (distal pancreatic resection, splenectomy, cholecystectomy, sphincteroplasty or colon resection) was also performed. Following surgery supportive therapy consisted of immunonutrition (glutamine and arginine supplementation) and modification of cytokine production by pentoxifyllin and dexamethasone. TNF and IL-6 serum levels were measured by ELISA and in vitro stimulation of leukocytes were induced by E. coli LPS. Results: Following surgery, continuous lavage and suction drainage were applied for an average of 42.5 days (range 21-90 days), with an average of 9.5 (range 5-20) litres of saline per day. The bactériologie findings revealed mainly enterai bacteria, but Candida infection was also frequently detected. The incidence of fungal infection was 21%. Forty patients (21%) had to undergo reoperation. The cytokine production capacity (TNF and IL-6) was shown to correlate with the prognosis. As a consequence of pentoxifyllin and dexamethasone therapy, the TNF production generally dropped to the normal level. The overall hospital mortality was 6.8% (13 patients died). Conclusion: In our experience, infected pancreatic necrosis responds well to comprehensive surgical treatment, continuous, longstanding lavage and suction drainage, together with supportive therapy consisting of immunonutrition and modification of cytokine production, combined with adequate antibiotic and antifungal medication.
ASJC Scopus subject areas