Debridement and closed cavity irrigation for the treatment of pancreatic necrosis.

Pancreatic and peripancreatic debridement combined with a closed cavity system of drainage was used to manage necrotic sequelae of severe acute pancreatitis in 14 patients. Intravenous contrast-enhanced computed tomography, or latterly incremental dynamic computed tomographic angiography, accurately detected and localized necrotic tissue. Operation was delayed where possible to permit demarcation of the necrotic area and the development of a 'capsule' of inflammatory tissue. A retrocolic route of access to the necrotic area was used in nine cases, and purpose-made silicone elastomer tubes with an outside diameter of 20 mm were positioned so that drainage was assisted by gravity when the patient was supine. The cavity was irrigated with saline (initially 2 litres daily), and in the last seven patients Trasylol was included in the irrigation fluid (5 x 10(6) kallidinogenase inactivator (KI) units/litre) for the first postoperative week. Three elderly patients died (mean age 72 years) but all patients aged less than 68 years survived. Planned reoperation was carried out in two patients, but further reoperations were not required in the remaining 11. Drainage tubes were removed when contrast studies showed the cavity to be small and superficial; the median duration of drainage was 28 days. Although sinograms demonstrated fistulae between cavity and small bowel (n = 4) or small bowel and colon (n = 2), no clinical problems resulted and all closed spontaneously. Closed drainage may be as effective as techniques of marsupialization, but avoids the need for frequent relaparotomy.