Management of infected pancreatic necrosis (IPN): Experience of a hepato-pancreatico-biliary (HPB) surgical unit

Abstract

Introduction: Pancreatic necrosis is a delayed local complication of severe acute pancreatitis. It carries considerable morbidity and mortality especially when complicated by infection. Management is a challenge in terms of determining the timing and strategy of intervention. This study outlines the surgical strategy and resultant morbidity in the management of IPN. Methods: Retrospective analysis of prospectively collected data was performed in patients who underwent surgery for IPN at an HPB surgical unit from August 2015 to October 2019. Results: Five patients were included in the study. All had multiple percutaneous, surgical or endoscopic drainage procedures. Organ failure occurred in 80% (4/5) with ARDS being the commonest. Intra-operative complications were colonic perforations 40% (2/5) and massive haemorrhage 20% (1/5). Necrotic material from all patients grew coliforms. Post-surgical morbidity included wound infection 80% (4/5), infected collections 40% (2/5), pancreatic fistulae (PF) 60% (3/5) and enterocutaneous fistulae 40% (2/5). Late complications were incisional hernias 100% (5/5), diabetes 40% (2/5) and keloid formation 20% (1/5). There was no exocrine failure or mortality. Median ICU and hospital stay were 17.2 (5-30) and 63 (40-89) days respectively. Median follow up was 33.6 (12-48 months). Conclusions: IPN carries a high morbidity. Timely and appropriate intervention with available resources and expertise can minimise mortality. Invasive open surgical strategies for drainage or necrosectomy by themselves carry a high morbidity with prolonged ICU and hospital stay. Increased availability of interventional endoscopic techniques promises good outcomes with less morbidity.