Open vs closed treatment of secondary pancreatic infections. A review of 42 cases

G. B. Doglietto, D. Gui, F. Pacelli, G. Brisinda, R. Bellantone, P. Crucitti, A. Sgadari and F. Crucitti
Department of Surgery, Policlinico Agostino Gemelli, Universita Cattolica del Sacro Cuore, Rome, Italy.

OBJECTIVE: To compare the results of closed treatment (CT) with the results of open treatment (OT) that uses laparostomy and marsupialization of the lesser sac in patients affected by secondary pancreatic infections. DESIGN: Retrospective cohort study. SETTING: Both primary and referral hospital care. PATIENTS: Forty-two patients undergoing emergency operations for unequivocal secondary pancreatic infections (infected pancreatic necrosis [n = 26] and pancreatic abscess [n = 14]) were retrospectively divided into two treatment groups on the basis of the operative treatment: conventional CT (n = 24) (1981 through 1986) and OT by laparostomy and marsupialization of the lesser sac (n = 18) (1987 through 1991). The OT and CT groups were homogeneous regarding demographic characteristics, mean APACHE (Acute Physiology and Chronic Health Evaluation) II score (17.1 +/- 6.0 vs 17.9 +/- 7.2, respectively; P value was not significant), and distribution of patients according to the type of pancreatic infection (infected pancreatic necrosis [13 vs 15, respectively] and pancreatic abscess [five vs nine, respectively]). The use of medical supportive care, including total parenteral nutrition and heavy doses of broad-spectrum antibiotics, was similar in both groups. MAIN OUTCOME MEASURES: Surgical complications; recurrent or persistent sepsis; postoperative death. RESULTS: The incidence of major surgical complications was 55.5% and 8.3% in OT and CT groups, respectively (P = .001). In OT and CT groups, signs of recurrent or persistent sepsis were observed in 5.6% vs 41.7% of the patients, respectively (P = .008): 7.7% vs 46.7% in patients with infected pancreatic necrosis (P = .02) and 0% vs 33.3% in patients with pancreatic abscess (P value was not significant). Overall mortality rates were 22.2% and 28.5% in the OT and CT groups, respectively (P value was not significant). The mortality rates due to recurrent or persistent sepsis in the OT and CT groups were 5.5% and 29.1%, respectively (P = .03). CONCLUSIONS: Although the frequency of major surgical complications after OT is significantly higher than that observed after CT, open drainage by means of laparostomy and marsupialization of the lesser sac controls pancreatic infection better, thus reducing mortality rate due to persistent or recurrent sepsis.