Infected pancreatic necrosis.

BACKGROUND: Infected pancreatic necrosis is a late infective complication of acute necrotizing pancreatitis in which infection tends to spread from the pancreas to the peripancreatic tissues, retroperitoneum, and, more rarely, the peritoneal cavity. Severe and rapid deterioration of the clinical condition may lead to septic shock and multiple organ dysfunction syndrome. CAUSATIVE ORGANISMS: The microorganisms most frequently isolated in cases of acute bacterial pancreatitis have been historically gram-negative bacteria of enteric origin. However, gram-positive cocci are isolated with increasing frequency. Enterococci are the single most commonly isolated species. TREATMENT: Aggressive multimodal therapy in the early stage of severe necrotizing pancreatitis improves survival; patients with infective complications tend to die later from multiple organ dysfunction syndrome. Initially, the treatment consists of fluids, analgesics, and oxygen supplementation. Surgical debridement should be limited to proved infections and delayed as long as possible to allow necrotic tissue to become demarcated. When surgery is necessary, blunt debridement of necrotic tissues is the procedure largely utilized and usually is not accompanied by excessive bleeding. Pancreatic resection should be reserved for massive necrosis of the gland substance. In many situations, the abdominal incision can be closed primarily. Treatment by the "open abdomen" technique should be reserved for those patients in whom further laparotomies are planned, mainly because of incomplete unsatisfactory debridement or uncontrolled bleeding that necessitates packing of the lesser sac.
CONCLUSION: Modern management techniques have reduced the mortality of infected pancreatic necrosis to 15-20% from historical rates that were twice as high. Aggressive resuscitation and surveillance of infection are crucial for successful outcomes, although fewer patients are undergoing surgical debridement.