Closed management

Since the early 1980s we have advocated surgical debridement (necrosectomy) supplemented by intra- and postoperative closed local lavage of the lesser sac for the treatment of necrotizing pancreatitis. Surgical debridement is performed either digitally or by the careful use of instruments to preserve still vital pancreatic parenchyma. Any tissue becoming necrotic after necrosectomy is rinsed out by the lavage fluid in the postoperative period. After surgical debridement an intraoperative lavage is performed using 6 to 12 liters of isotonic saline to clear the surface of the pancreatic bed. For postoperative continuous local lavage, large-bore single-lumen (Ch 24-28) and double-lumen (Ch 16-18) catheters are placed into the lesser sac. The gastrocolic and duodenocolic ligaments are sutured to create a closed compartment for a regionally restricted lavage. Initial postoperative continuous lavage is performed using 24 liters of commercial dialysis fluid per day. This is discontinued when the effluent is clear with no signs of active pancreatic enzymes or positive bacteriology. The overall mortality of closed management in necrotizing pancreatitis ranges from 9 to 23 per cent.

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