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Invited Critique |

Invited Critique: Reoperation for Severe Pancreatitis

Edward L. Bradley III, MD
Arch Surg. 1999;134(3):321. doi:10.1001/archsurg.134.3.321.
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The preceding article from our French colleagues focuses on a difficult subgroup of patients with necrotizing pancreatitis in whom an initial surgical exploration failed to control sepsis. Their reoperative approach consisted of extensive debridement of residual necrosis, exteriorized Mikulicz packs, feeding jejunostomy, biliary drainage, and loop ileostomy whenever colon viability was problematic. After 2 weeks, packs were replaced with proprietary silicon drains, which were exchanged daily and continuously irrigated. Since this approach is essentially a modification of lesser sac lavage, it is not surprising that their 23% mortality rate is comparable to traditional lesser sac lavage.1 Several comments are in order. Infected pancreatic necrosis was present in 82% of these previously surgically explored patients, a significantly greater incidence of infected necrosis than the 20% incidence of infected necrosis in unoperated necrotizing pancreatitis.2 Surgically induced secondary infection of sterile pancreatic necrosis is a real risk and results in measurable escalation of mortality.3 When combined with prospective observations that neither mortality nor morbidity is improved by surgical debridement when compared with supportive therapy,4 the rationale for surgical intervention in sterile necrotizing pancreatitis is, at best, unclear.

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