Drainage of a Pancreatic Abscess

Drainage of a Pancreatic Abscess

Operative Indications

Pancreatic abscess and/or sepsis is the major cause of morbidity and mortality in acute pancreatitis. Early diagnosis is essential if pancreatic debridement and drainage is to be performed early enough to prevent life-threatening morbidity. With CT scanning to identify peripancreatic fluid collections and areas of necrotic pancreas with or without air bubbles and with the ability to fine-needle aspirate fluid collections to look for bacteria, the diagnosis of a pancreatic abscess often can now be made relatively early in its development. When the diagnosis is made, the patient should be stabilized and taken to the operating room as soon as possible.

Operative Technique

Either a long midline or a bilateral subcostal incision can be used. Adequate exposure is particularly important as it is essential that the entire abdomen be explored for extensions of the abscess away from the pancreas, down either paracolic gutter, into the transverse mesocolon, or into the left or right upper quadrants.

Once the abdomen is entered the omentum is divided widely so that the entire lesser sac can be exposed. Rather than large collections of pus, the more frequent finding is of grumous necrotic material filling the lesser sac and surrounding the pancreas.

It is essential that the entire abdomen be explored for extensions of the abscess out of the lesser sac. The transverse colon is being reflected in a cephalad direction, identifying extension of the abscess inferiorly in the retroperitoneum, and into the root of the transverse mesocolon.

It is important to take down the hepatic flexure and mobilize the right colon out of the retroperitoneum to be certain the abscess does not extend down the right gutter. This is one of the most common sites of extension that is missed at laparotomy for a pancreatic abscess.

Generally, this is a good time to extensively kocherize the duodenum to be certain there are no extensions from the head of the gland in a cephalad direction. The left colon should be mobilized in a similar fashion.

Extension of the abscess down the left gutter can be seen.

Debridement of the necrotic grumous material has begun at the root of the transverse mesocolon. Debridement can be carried out sharply using scissors, but generally blunt debridement using one’s fingers or instruments such as the sponge forceps pictured here is preferred.

What often appears initially to be necrotic pancreas is usually fat necrosis and inflammatory debris that is actually on top of and surrounding a still viable pancreas. During this phase of the debridement it is essential to follow the abscess out to the tip of the tail of the pancreas, to be certain that one does not miss extension of the abscess into the left upper quadrant under the left hemidiaphragm.

Once the debridement has progressed to the point where further debridement results in bleeding, extensive irrigation should be carried out. We prefer a dilute antibiotic-containing saline solution. Overly aggressive debridement can lead to bleeding that is very difficult to control.

Following adequate debridement, two options are available to achieve drainage. One option is to insert a series of silastic sump and Penrose drains into all of the various extensions of the abscess. In this patient, the lesser sac, left paracolic gutter, the root of the transverse mesocolon, and the retroperitoneum at the root of the mesocolon have all been debrided and drained.

Once the drains have been inserted, the abdomen is closed (assuming that all of the nonvital tissue has been removed). As the patient improves, sinograms can be obtained through the axiom sump drains, and eventually all of the drains will be slowly advanced out as healing occurs.

Another option for drainage is to pack the entire lesser sac and all extensions of the abscess with Mikulicz’s pads. The corner of each Mikulicz’s pad with the ring tag is brought out through the middle of the incision. These packs are placed with the intention of changing them every two or three days, thereby continuing to mechanically debride the abscess cavities.
The upper and lower portions of the wound are closed with large stay sutures of No. 1 nylon, with rubber bumpers constructed from French catheters. The dressings can be periodically saturated postoperatively with antibiotic-containing solutions. The initial repacking should be done under general anesthesia in the operating room in 48 hours. Eventually, however, the repackings may be performed under heavy sedation in the intensive care unit.

The packing changes continue every two or three days until the abscess is thoroughly debrided and the cavity has started granulating. This usually takes several packing changes.

At this point one can insert Penrose and sump drains as demonstrated previously and close the abdominal wound. The other option is to continue the packings until granulation and contracture have progressed to the point where the cavity has actually closed. This option takes longer, but is perhaps safer.

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