Surgical treatment of necrotizing pancreatitis by marsupialization

The ideal surgical treatment for necrotizing pancreatitis remains a matter of debate. To provide adequate drainage and egress for large fragments of devitalized pancreas as well as access for interval debridement, three patients with significant pancreatic necrosis underwent debridement of devitalized pancreas and open packing (marsupialization) of the lesser space. The etiologies of pancreatic necrosis included trauma in one patient, an infected pancreatic pseudocyst in another patient, and acute alcoholic pancreatitis in the third patient. After the initial operative procedure, patients were returned to the operating room at interval of 2 to 5 days for further debridement and dressing changes. Clinical improvement was observed almost immediately after the initial procedure, although the rate of recovery varied from patient to patient. No deaths occurred. Two procedure-related complications occurred: development of a loculated fluid collection in the left paracolic gutter that required surgical drainage and an injury to the splenic artery requiring arteriorrhaphy. Late complications included a ventral hernia and a persistent duodenocutaneous fistula. Marsupialization along with limited debridement is recommended as an alternative to closed drainage of the peripancreatic space in patients with significant pancreatic necrosis.