Prevention, diagnosis, and treatment of pancreatic abscess.

Since pancreatic abscesses are a highly lethal complication of acute pancreatitis, factors influencing the genesis of major peripancreatic infection (MPI) were analyzed in 330 patients with pancreatitis. MPI developed in 28 (8.5%). Management of MPI was reviewed in 35 patients, including seven admitted with MPI. Etiology and severity of pancreatitis influenced MPI frequency. MPI was common in postoperative pancreatitis (39%), compared with alcoholic (6.6%), biliary (3.6%), or other causes (15%). "Severity" of pancreatitis was estimated by 11 early prognostic signs, which were reported previously. With fewer than three signs, MPI developed in 2.7%, three to five signs, 32%; more than five signs, 50%. Treatment of pancreatitis also influenced MPI. Early laparotomy increased MPI incidence from 1.6% to 23% in mild pancreatitis and from 24% to 67% in severe pancreatitis. Early oral feeding also appeared to predispose to MPI. Prolonged nasogastric suction and avoidance of early operation reduced MPI incidence from 16% in the first 100 patients to 5% in the next 230 patients. Outcome of MPI reflected severity of underlying pancreatitis. Mortality with fewer than three signs was 14%; with three to five signs, 65%; with more than six signs, 100%. Mortality was only 26% in 19 patients treated with radical sump drainage of the entire peripancreatic retroperitoneum, compared to 75% of 16 patients treated with conventional local drainage. In summary, MPI is related to etiology and severity of pancreatitis as quantified by early signs. Early laparotomy for pancreatitis increased MPI. Treatment of MPI with wide sump drainage appears more effective than local drainage.