Surgical management of late sequelae in survivors of an episode of acute necrotizing pancreatitis

Background: After surviving an episode of acute necrotizing pancreatitis (ANP), a variety of late sequelae develop and require nonoperative or operative interventions. Persistent pancreatic fistula, fluid collections, recurrent pancreatitis, sepsis, pain, and intolerance of po intake are seen. Study Design: We have maintained records for all patients hospitalized from 1993 through 2010 with a diagnosis of ANP. Once discharged from hospital, patients were managed with routine clinic follow-up at close intervals and later at 6-month intervals. Using ERCP or magnetic resonance cholangiopancreatography, all patients' pancreatic ducts were classified as type I (normal), type II (stricture), or type III (disconnected). Patients were monitored for the complications mentioned. Operations performed >8 weeks after the initial episode of ANP were defined as late and evaluated for operative mortality, morbidity, success in resolving symptoms/collections, and length of stay. Results: One hundred and ninety-seven patients with ANP were included. Seventy-one late operations were performed (59 drainage procedures/12 resections). Operative mortality was 1%, morbidity was 19%, and mean length of stay was 6.3 ± 5.6 days. Poor po intake was seen in 80% of operated patients and total parenteral nutrition dependence in 42%. Duct type correlated with pancreatic debridement, persistent fluid collection/fistula, pain, po intake intolerance, and late operation. Late operation successfully resolved symptoms and/or fluid collections in 96%. Recurrent pancreatitis was improved in 87% and eliminated in 78%. Conclusions: Patients who require late operation after surviving an episode of ANP are more likely to have sustained ductal injuries and are likely to require operation for either pain or for inability to tolerate po intake. Operation can be performed safely with a low mortality.