Percutaneous Lavage as Primary Treatment for Infected Pancreatic Necrosis

BACKGROUND: The classic treatment of infected pancreatic necrosis (IPN) is surgical debridement and drainage. This study reviews our experience with nonoperative percutaneous catheter drainage and serial lavage as primary treatment in patients with IPN. STUDY DESIGN: Between 1993 and 2009, a prospective nonselected series of 63 consecutive patients with microbiologically confirmed IPN were enrolled with the intent of treating them nonoperatively, and they were retrospectively analyzed. Catheters were placed percutaneously in the interventional radiology (IR) suite, and were used to lavage and debride the necrosis 1-3 times per week. The lavages continued on an outpatient basis by IR, and the catheters were removed with disease resolution. RESULTS: One patient rapidly became unstable and had to be taken primarily for open debridement. In the remaining 62 patients, 57 survived, for an overall mortality rate of 8%. Fifty patients were treated solely with percutaneous lavage, and 47 survived. Mean hospital length of stay was 61 days, ranging from 6 to 190 days. Mean length of outpatient treatment was 42 days, ranging from 3 to 180 days. Mean number of lavages was 21, ranging from 11 to 75. Eleven patients (18%) deteriorated during percutaneous treatment and required laparotomy, and 9 of these survived. One patient treated percutaneously resolved his sepsis but had a persistent pancreatic fistula and was managed with pancreaticojejunostomy. CONCLUSIONS: Percutaneous catheter drainage and serial lavage are an effective alternative to open surgical debridement in patients with IPN. Overall survival is excellent, and most patients avoid the morbidity of open debridement. A minority of patients deteriorate, but most of those can be salvaged with open drainage. (J Am Coll Surg 2011;212:748-754. (C) 2011 by the American College of Surgeons)