The appropriate treatment of sterile necrosis (SN)in severe acute pancreatitis is still a matter of controversies. in this respect surgicaltreatment has been claimed to carry the risk of secondarypancreatic infections (sP). However, no study has ever addressed this issue in a larger seriesof patients subjectedto surgery of SN.
Materials and METHODS: Between 05/82 and 12/97 241 pat. with necrotizing pancreatitis were treated by necrosectomy and closed continuous lavage of the lesser sac at our institution. 107 (44.4%) pat. had primary infected necrosis (pIN), whereas 134 (55.6%) were found to be sterile by intraoperative bacteriology. In the latter group 119 pat. were further analyzed and stratified into the three entities: I. secondary pancreatic infections (sPI) proven by reinterventions, II. contaminations (CON) proven by positive bacteriology from abdominal drains without the need for reinterventions, and III. sterile courses (STER).
RESULTS: In 119 pat. with intraoperatively proven SN sPI were found in 47 (39.5%), CON in 63 (52.9%), and STER in 9 (7.6%) pat. The disease severity in terms of Ranson- (sPI 7 vs CON 3, p<0.0001) and admission Apache II-scores (sPI 16 vs CON 9, p<0.001), incidence of early organ complications (p<0,03-0.001), and preoperative extent of intrapancreatic necrosis > 30% shown by contrast-enhanced CT (sPI 57% vs CON 33%, p<0.03) was higher in the sPI- than in the CON-group. Compared to pat. with primary IN a significant shift to gram-positive bacteria (p<0.05) was observed with gram-negative organisms (p<0.001) being less frequently found in both the sPI- and CON-group. In both respective groups antibiotics had been administered significantly longer than in pat. with primary IN until the intraoperative diagnosis of infection was made. Whereas the CT proven extent of necrosis was the same in pat. with primary IN and sPI the overall disease severity (Ranson pIN: 4 vs sPI 7, p<0.001, APACHE: II pIN 12 vs sPI 16, p<0.03) and incidence of early organ complications (p<0.04-0.001) was higher in the sPI-group.
CONCLUSIONS: Patients with sPI represent a distinct entity characterized by a high clinical and morphological severity early in the course of the disease. Herein, we suggest initial pathophysiologic events and not the surgical procedure itself being a major determinant of subsequent sPI.