Surgical Science, 2010, 1, 7-14
doi:10.4236/ss.2010.11002 Published Online July 2010 (http://www.SciRP.org/journal/ss)
The Open Packing of the Lesser Sac Technique in Infected
Severe Acute Pancreatitis
D. Cochior1 S. Constantinoiu2, D. Peţa1, Mariana Cochior3, Rodica Bîrlă2, L. Pripişi1
1Clinical Hospital CF 2 Bucharest, Department of Surgery, Research Department, Faculty of Medicine of the
University Titu Maiorescu, Bucharest, Rumania
2Clinical Hospital, “Santa Maria” Bucharest, Department of General and Esophageal Surgery University of
Medicine and Pharmacy Carol Davila, Bucharest, Rumania
3Emergency Clinic Hospital, Intensive Care Unit, University of Medicine and Pharmacy
Carol Davila, Bucharest, Rumania
Received April 14, 2010; accepted May 11, 2010
Abstract
Aim: The goal of this study is to evaluate the open packing of the lesser sac (OPLS) in treatment of infected
severe acute pancreatitis Methodology: The study was based on 98 cases in which this technique was ap-
plied during the period between 1994-2007, in two departments of surgery (Clinical Hospital CF 2 and
Clinical Hospital „Sf. Maria” Bucharest). The technique was applied based on the therapeutically protocol
previously established beginning with 2000. The OPLS technique was analyzed relatively to: timing of sur-
gery, the localization of the infected necrosis or abscesses, growing germs on the cultures, antibiotics re-
ceived, executed primarily or at re-intervention, the number of debridement, hospitalization, morbidity and
mortality. The information was statistically processed using SPSS test version 17 for Windows. Results: The
OPLS technique improved the control of the local sepsis, in the retrospective/prospective study in 83.7%.
Mortality was 16.3% (16/98), with a global mortality of 26.3% (75/285) and a postoperative mortality of
29.5% (66/224). Conclusions: Considering the fact that the intensive care techniques are approximately the
same in the last 15 years, we thought that this improvement in the survival rate may be due to the application
of OPLS in cases with indication and optimal timing for surgery.
Keywords: Open Packing of the Lesser Sac (OPLS), Severe Acute Pancreatitis (SAP), Infected Necrosis,
Pancreatic Abscess and Necrosectomy
1. Introduction
Surgical intervention in infected SAP has as its main aim
to counteract the effects of local septic complications [1].
There are still divergent opinions regarding surgical
techniques adopted to be effective in treating pancreatic
and extrapancreatic infections [2]. The decision of using
a certain surgical technique after necrosectomy is indi-
vidual and depends on the evolution of the disease, the
timing of surgery, the extension of the pancreatic or ex-
trapancreatic necrosis and on the surgeon’s experience [3,
4]. The usage of semi-open abdomen as in infected SAP
therapy was first described in 1894 by Korte [5,6]. More
recently, Bradley [7] has shown decreased mortality by
using semi-open abdomen and subsequent re-explora-
tion.
2. Material and Method
Due to unsatisfactory results arising from the retrospec-
tive analysis (1994-1999) after using pancreatic resection
or a necrosectomy followed by multiple peritoneal
drainages and closure of the abdominal wall, we adopted
the therapeutic protocol based on aggressive intensive
care, necrosectomy and semi-open abdomen technique,
respectively the open packing of the lesser sac (OPLS)
(prospective approach 2000-2007). The analysis includes
947 cases with acute pancreatitis admitted between 1994-
2007, in the 2 clinics (Clinical Hospital, Santa Maria”
and Clinical Hospital CF 2 Bucharest) of which 285
cases with severe form (152 cases of male and 133 fe-
male, the average age of 53.2 years). Of these 224
(78.6%) cases have undergone surgical intervention and

8 A. HIGGINS ET AL .
61 (21.4%) cases were treated conservatively. In data
processing we used information provided by the admis-
sion on the evaluation sheet of the patient with acute
pancreatitis within 72 hours (prospective approach) and
information from the file of the patient during hospitali-
zation: general information (age, sex, history, associated
diseases, mode of onset, body mass index – BMI > 30
kg/m2), clinical data, laboratory data, severity scores
(Glasgow to admission and to 48 hours, modified
APACHE II score for acute pancreatitis), etiology of
pancreatitis, Multiple Organs Dysfunction Syndrome
(MODS), results of microbiological cultures performed
before surgery (CT-FNA), during surgery and after sur-
gery, imaging investigations (ultrasound, pulmonary ra-
diography, computerized tomography) antibiotherapy
(prophylactic and curative), duration of hospitalization,
duration of hospitalization in ICU, timing of surgery,
data obtained during surgery (extension of the pancreatic
and extrapancreatic necrosis, cholecystitis, biliary path-
ways, ascites, associated visceral lesions), conservative
and surgical treatment applied, outcomes (healing, com-
plications, recurrence, re-interventions), mortality and
necropsy data.
The retrospective/prospective study was analyzed by
etiological forms with specific therapeutic management,
and timing of surgery was analyzed with the benchmark
of 21 day according to the studies of Fernández del Cas-
tillo [8] and recommendations of the International Asso-
ciation of the Pancreatology (immediate emergency < 72
hours, within 3 weeks or after 3 weeks) [9]. In 98 cases
we have adopted the OPLS technique without forcing its
application where it wasn’t indicated, according to the
intra operative findings. We found that the combination
of pre and post operative measures with this technique
(OPLS) can significantly reduce mortality in this disease.
The OPLS technique was analyzed in several ways:
timing of surgery, location of infected necrosis or ab-
scesses, microbiological cultures, antibiotics treatment, if
it was done at first surgical intervention or at the reinter-
vention, number of debridement’s, duration of hospitali-
zation, duration of hospitalization in ICU, morbidity at
short and long time and quality of life after surgical in-
tervention. All elements have outlined the value of the
OPLS technique in surgical management of the infected
SAP.
3. Outcomes
The surgical technique we applied was the classical one
with several improvements. Firstly, the timing of inter-
vention is delayed until the occurrence of the clearly de-
fined infected necrosis [3,10,11] (Figure 1).
Secondly, we limited the propagation of infection in
submesocolic peritoneal cavity by creating this omental
laparostomy with suturing the cutting edges of the gas-
trocolic ligament to the supra-umbilical anterior parietal
peritoneum, near to the laparotomy, achieving the, mar-
supialisation” of the lesser sac [5,12]. With this maneu-
ver we protect submesocolic region by creating an
“omental wall”. Another major advantage of our ap-
proach was the subsequent necrosectomy, daily during
the first week, which was accompanied by the change of
dressings and packing gauzes. In sterile conditions, in
operation room under epidural anesthesia, the patients
are submitted to local washing with soft disinfectants
(hydrogen peroxide, bethadine, chlorhexidine), and re-
debridement under visual control. At this time we per-
form the cleaning of the drainage tubes probably clogged
by the organic debris, sampling for microbiological ex-
ams of the necrotic debris extracted, fluid secretion of
the wounds, possibly secretions occurring at the drainage
tubes when they had suppurative aspect, followed by
repositioning of the packing gauzes (Miculicz type) in
the omental laparostomy (Figure 2).
“Targeted” antibiotherapy and antifungal medication
was initiated according to the microbiological results.
Simultaneously we carefully perform haemostasis in the
areas of necrosectomy, even with the harmonic scalpel if
the situation required it. In order to avoid the formation
of gastric or colic fistulas we imbued the adjacent pack-
ing gauze of these areas with sterile paraffin oil. In this
Figure 1. Intraoperative findings: infected necrosis with
suppurative pancreatic ascites.

A. HIGGINS ET AL .
9
way, the patient that undergoes surgical intervention was
evaluated at least once a day by the operative surgeon.
It is important that the patient is observed by the same
surgeon because in this way he will be “familiar” with
systemic and local particularities of the case and take the
right decisions regarding the necessity of the necrosec-
tomy in the remaining areas of necrosis after surgery and
will be able to identify early those arising in the evolu-
tion. Sometimes, areas of evolving deep necrosis cannot
be identified during the changing of the packing gauzes
but they are suggested by the patient’s clinical decline. In
these situations we used the CT scan to identify areas of
evolving necrosis exploring hidden to the laparostomy
and which require a formal re-exploration. After a period
of 7 to 10 days (after granulation in this area) patients are
examined at laparostomy, using soft sedation, in the ICU
or at room dressings, under strict aseptic conditions.
Only non-viable tissues are removed using digital de-
bridement or blunt instruments, sometimes necrotic ma-
terial was removed when changing the packing gauzes
by using washing fluids (Figure 3).
The diagnosis of microbiological status of pancreatic
and extrapancreatic necrosis was performed in the basis
of clinical pathological correlations using macroscopic
findings and results of bacterial cultures.
Microorganisms responsible for secondary infection of
pancreatic and extrapancreatic necrosis of this study are
listed in Table 1.
It is known that the success of any aggressive or radi-
cal approach, of a disease such as acute severe infected
pancreatitis, depends largely on the degree of coopera-
tion between the surgeon, anesthesiologist, radiologist
and microbiologist [11]. At the opening of the peritoneal
cavity, this is subjected to exogenous contamination. It
takes place a double contamination of the pancreatic and
extrapancreatic necrosis by the secondary nosocomial
micro-organisms with low sensitivity to antibiotics. Sep-
ticemia caused by exogenous or endogenous flora is the
most common cause of mortality in severe acute pan-
creatitis [1,9].
The accurate microbiological diagnosis with the evi-
dence of the sensitivity of the microbial flora, targeted
antibiotherapy and a proper hygiene strategy represent
the most important requirements of the therapeutic man-
agement in the cases of the OPLS technique. At the level
of the laparostomy, peritoneal fluid, blood and purulent
secretions are the most significant concerning the results
from the microbiological point of view.
The hemogram, and the cultures for aerobic and an-
aerobic flora with antibiogram must be made attentively
in both situation: nonsurgical patients (possible “gates of
entry” for infection of the necrosis) and at the operated
patients (laparostomy).
In the retrospective/prospective study the OPLS tech-
nique was performed in 11 cases at reinterventions
(11.2%). The OPLS technique applied in these cases is
more laborious and predisposes to an increased risk of
bleeding or pancreatic tissue injury, spleen or adjacent
cavitare organs. The main operative indication in these
cases is secondary infected necrosis, after unexpected
emergency laparotomy after 14 days of evolution of the
disease or when the surgeon feels that he had a “total
control” over pancreatic and extrapancreatic necrosis at
Figure 2. View of infected evolutive necrosis within 7 days
after surgery. Notice small necrosis with trend of detach-
ment from viable tissue. Final appearance after dressing
(box).
Figure 3. View of the extracted necrosis to re-explorations
trough the lesser sac laparostomy.

10 A. HIGGINS ET AL .
Table 1. Bacteriology of secondary infected necrosis, during
treatment with OPLS technique.
Microorganism N = 62
Escherichia coli 15
Klebsiella pneumoniae 7
Staphilococus aureus 8
Pseudomonas aeruginosa 5
Enterococcus faecalis 3
Candida albicans 8
Polimicrobian infections 16
the first intervention and he closed the abdomen with
simple drainage.
This secondary infection of the pancreatic and extra-
pancreatic necrosis is the determining factor of recur-
rence of MODS and, subsequently, high risk of death,
even if not all forms of secondary infection present the
same risk. Infected acute pancreatic pseudocyst and pan-
creatic abscess have had a low rate of mortality com-
parative with infected diffuse necrosis [1,4].
Consequently, in the effort to improve survival rate in
severe acute pancreatitis special attention should be
given to the therapeutic management of these secondary
infections, especially on the secondary infected necrosis.
Following our experience we believe that the OPLS
technique is a good alternative in terms of surgical tech-
nique to apply in these complications difficult to treat. In
order to prevent digestive fistulas of the organs around
the laparostomy (stomach, colon, duodenum) we used
protection foil, from plastic material, non adherent,
which allowed the leak of the secretion to the exterior.
We use these foils 5-6 days after surgical intervention
when the wounds begin to granulate to prevent suppura-
tive complications of the abdominal wall. Near the limits
of the laparostomy we used only non absorbable mono-
filament threads (USP 0), to prevent eviscerations espe-
cially for the patient’s witch require mechanical ventila-
tion after surgery.
In order to change the dressings and packing gauzes,
epidural or intravenous anesthesia is required a certain
period (usually 12 to 14 days). After the granulation of
the retroperitoneal space and repeated sterile cultures, the
abdominal wall may be secondary closed if the abdomi-
nal wall did not retracted and allow this maneuver [5,13,
14]. We preferred to let the wound to heal per secundam
for better survey to avoid encystations of any collection
or these one may spontaneously evacuate trough the
laparostomy.
Also, the occurrence of the pancreatic fistulae allows
initial exteriorization at this level, therapeutic measures
will be adopted as necessary depending on the flow and
persistence of the fistula. In most cases (n = 77; 78.6%)
the abdominal wall closed secondarily did not required
reintervention for the occurrence of the eventration after
6-8 months (Figure 4).
Consecutively of applying of this technique (n =
98;43.75% with n = 87 at first intention and n = 11 at re-
intervention) the mortality recorded in this group was
16.3% (16/98) better than a overall mortality 26.3%
(75/285) or that of the patients operated using other sur-
gical procedures 52.4% (66/126). Causes of postopera-
tive morbidity and mortality are shown in Table 2.
Only 2 cases died because of recurrent sepsis. Hepatic
insufficiency has been associated with other causes of
death. 1 case had septicemia with Pseudomonas resistant
to antibiotherapy and another by massive digestive
bleeding due to infection with Candida without response
to fluconasol systemically administered. In other cases,
death occurred after the signs of sepsis had been eradi-
cated.
Under these conditions of the severity of disease, the
morbidity was quite high. External pancreatic fistulas (n
= 17) and 1 case with incomplete duodenal obstruction
have evolved over time, 2 of them requiring surgical
treatment and the patient with duodenal obstruction was
submitted to exclusion gastric resection 6 months after.
Medical complications (exocrine and endocrine dys-
function) in fact reflect the percentage of the pancreatic
tissue lost infective during the infectious process. Only
Figure 4. Per secundam healing of the lesser sac.

A. HIGGINS ET AL .
11
17 cases had eventrations and required surgery to cure it
with prosthetic mesh after 6-8 months. Chronic pan-
creatitis occurred in 28 cases (28.6%), documented
clinically by persistent pain and recurrent diarrhea and
calcification in the pancreatic area at CT scan, micro-
lithiasis of the Wirsung and typical aspects to the ERCP
or MRI colangiopancreatography examination.
The weight of the necrotic tissue removed in the oper-
ating room and subsequent necrosectomies was meas-
ured only at the last 15 patients (Table 3). The average
weight of the necrotic tissue removed intra operatively
was 200 ± 80g, with the remaining quantities of necrotic
tissue occurred in evolution after surgery being removed
from further re-exploration through laparostomy. The
possibility of removal of infected necrotic tissue oc-
curred in the evolution is the biggest advantage of the
OPLS technique compared with the closed abdomen
techniques.
The average hospitalization of the patients undergoing
OPLS was 54 days (31-82) to discharge with duration of
hospitalization in ICU, averaging 22 days (18-27). The
period of hospitalization does not differ essentially com-
parative with those studies that refer to the use of closed
techniques, and is closer to those that refer to the use of
technique of closed lavage of the lesser sac. The average
number of the re-explorations was 11 (5-16) (Table 4).
The necrosis was strictly limited to the pancreas to a
small percentage of cases (in prospective study n = 28;
15.6%). In the retrospective study only 9 cases (12.5%)
had infected necrosis strictly limited to the gland. Most
patients presented extensive extrapancreatic necrosis to
the lesser sac region, in the subphrenic left region, in the
root mesentery, retrocolic or in pelvic region (in pro-
spective study n = 152; 84.4%).
Using the numerical criteria of extrapancreatic necro-
sis we divided the study (retrospective and prospective)
into two subgroups: cases with maximum 2 areas of the
extrapancreatic necrosis and cases with more than three
areas of the extrapancreatic necrosis. In the retrospective
study, the abdomen was closed in most cases and multi-
ply drained (75/90; 83.3%), only 13 cases OPLS tech-
nique was applied at the first intervention and in 2 cases
at reintervention.
In the prospective study, the abdomen remained
semi-open at the first intervention in 61.9% of the cases
(n = 83/134) and in 9 cases of reintervention, with an
evident increase in the group with more than 3 areas of
extrapancreatic necrosis from 29.5 to 41.5% (Table 5).
Concerning the complete necrosis of the pancreas the
percentage in the retrospective study (n = 7; 6.7%) was
higher comparative with the prospective study (n = 5;
3.7%), but increases the frequency of using the OPLS
technique (Table 6). This extension of the necrosis is not
statistically significant in terms of surgical therapy (p =
0.9) but only in terms of frequency of infected necrosis
(p < 0.05).
Table 2. The results in infected pancreatic necrosis after
applied the OPLS technique.
MORTALITY n = 16/98; 16.3%
Recurrent sepsis n = 2; 2%
Hepatic insufficiency n = 14; 14.3%
Myocardial infarction n = 1; 1%
Pulmonary embolism n = 1; 1%
Hemorrhages n = 1; 1%
MORBIDITY (local postoperative complications)
External pancreatic fistula n = 17; 17.4%
Eventrations n = 17; 17.4%
Intestinal occlusion n = 2; 2%
Hemorrhages from major vessels n = 4; 4.1%
Enteral fistula n = 2; 2%
Gastric fistula n = 2; 2%
Colic fistula n = 4; 4.1%
MORBIDITY (systemic postoperative complications)
Pneumonia n = 6; 6.1%
Renal insufficiency n = 17; 17.35%
Table 3. The weight of the necrotic pancreatic and extra-
pancreatic tissue removed at surgery and subsequent re-
explorations.
n = * Weight (g) Weight range
Operative exploration 15 200 ± 50 50-250
First re-exploration 15 70 ± 30 30-100
A second re-exploration 15 60 ± 30 20-90
A third re-exploration 15 40 ± 20 20-60
The fourth re-exploration15 30 ± 15 7-45
The fifth re-exploration 15 20 ± 12 0-32
Sixth re-exploration 13 15 ± 7 0-23
Table 4. OPLS – Postoperative re-debridement.
Number 1-4 5-8 9-13 14-15 > 15
Cases (n = 98) 0 19 67 12 1
Table 5. The incidence of areas of the extrapancreatic ne-
crosis in retrospective/prospective study.
Documented cases
n = 213
Extrapancreatic ne-
crotic areas Cases%
0-2 43/6170.5
Retrospective study3-5 18/6129.5
0-2 89/15258.5
Prospective study 3-5 63/15241.5
0-2 87/11575.7
Closed abdomen 3-5 28/11524.3
0-2 35/9835.7
OPLS 3-5 63/9854.3

12 A. HIGGINS ET AL .
Table 6. The incidence of partial or total necrosis of the
pancreas in retrospective/prospective study.
n = 224 operated cases Pancreatic necrosis Cases %
Partially 83/90 93.3
Retrospective study Totally 7/90 6.7
Partially 129/13496.3
Prospective study Totally 5/134
3.7
Partially 120/12695.2
Closed abdomen
n = 126/224 Totally 6/126
4.8
Partially 92/98 93.9
OPLS
n = 98/224 Totally 6/98
6.1
Reinterventions frequency is higher in the retrospec-
tive study (3 patients in this group required 3 reinterven-
tions). The deceases in the cases operated occurred in the
group with reinterventions in a percentage of 52.9%
(45/85) (Table 7).
The increased rate of the reintervention is correlated
with the extension of the pancreatic and extrapancreatic
necrosis: 78.8% (n = 67) in the group with 3 or more
areas of necrosis vs. 11.8% (n = 18) in the group with
only 2 areas of necrosis (Table 8) and 75% (n = 9/12) at
patients with complete glandular necrosis vs. 35.8% (n =
76/212) patients with partial glandular necrosis (Table
9).
Since 2000 we have embedded the concept of the
OPLS technique in the therapeutic protocol of the in-
fected SAP because of the high percentage of the rein-
terventions. Initially, when we suspected further evolu-
tion with extensive infected, evolving necrosis, after in-
traoperative exploration of the abdomen, the closure of
the laparostomy was avoided.
The number of the necrosectomies subsequent of the
interventions at patients first treated by OPLS technique
is correlated with the extensions of the extrapancreatic
necrosis but not with the extension of the organ necrosis.
Patients with three or more areas of the extrapancreatic
necrosis required frequent redebridement (more than 12),
while patients with maximum 2 areas of extrapancreatic
necrosis the average of necessary redebridements was 6
(Table 4).
This assessment of extrapancreatic necrosis extension
shows that this is the best criteria of decision, in such
patient, to use or not the OPLS technique.
Analyzing the incidence of the MODS, pre and post
surgery and the mortality, we considered, firstly, the
number of renal, pulmonary and cardiac dysfunctions. In
the group of patients treated with OPLS technique (n =
98) we found preoperative increased incidence of renal,
pulmonary and cardiac dysfunction (Tables 10 and 11).
In the group operated without MODS we recorded 3
deaths (3/224). Patients operated with MODS and who
deceased were n = 63 (63/224). Analyzing the postopera-
tive rate of complications on patients to which the OPLS
technique was performed and patients to which was per-
formed closed abdomen we found it quite high in both
groups.
Comparing the mortality from the point of view of a
specific organ dysfunction it can be concluded that at
patients with closed abdomen and drainage at first inten-
tion the development of postoperative organ dysfunction
Table 7. The incidence of the reinterventions after necro-
sectomy with closed abdomen in retrospective/prospective
study.
Reintervention
Reintervention 85/224 1 2 3 456
Retrospective study (n = 48/90; 53.3%)
38 6 3 - - 1
Cases
Deaths 21 4 2 1
Prospective study (n = 37/134; 27.6%)
27 7 3 - --
Cases
Deaths 11 5 2
Table 8. The incidence of the reinterventions after necro-
sectomy with closed abdomen and frequency of the de-
bridements after OPLS technique correlate with the num-
ber of the areas of extrapancreatic necrosis in retrospec-
tive/prospective study.
Reintervention
Reinterven-
tions 85/224
Number of
the areas of
extrapan-
creatic
necrosis
n %
0-2 17/48 35.4
Retrospective
study Closed
abdomen 3-5 31/48 64.6
Iterative debridement
1-4 5-8 9-13 14-15 >15
0-2 (8/37) 0 6 2 - -
Prospective
study
OPLS tech-
nique 3-5 (29/37)0 8 11 9 1
Table 9. The incidence of the reinterventions after necro-
sectomy with closed abdomen and frequency of the de-
bridement after OPLS technique correlate with the partial
or total necrosis of the pancreas in retrospective/prospect-
ive study.
Reintervention
Reinterven-
tions 85/224
Pancre-
atic
necrosis n %
Partially42/48 87,5
Retrospective
study Closed
abdomen Totally 6/48 12,5
Iterative debridement
1-4 5-8 9-13 14-15 >15
Partially
(31/37;
83.8%)
0 4 19 8 -
Prospective
study
OPLS tech-
nique Totally
(6/37;
16.2%)
- 1 2 2 1

A. HIGGINS ET AL .
13
is more frequent compared with those on which was
practiced the OPLS technique. At patients who survived
(in both retrospective and prospective studies) mechani-
cal ventilation was required in the postoperative period
in 11 cases, postoperative pain was reduced, intestinal
transit was quickly resumed and allowed early mobiliza-
tion of the patient.
4. Discussions
We emphasize that the technique (OPLS) allowed con-
trol of the sepsis in retrospective/prospective study in
83.7% of cases. Mortality recorded was 16.3% (16/98) in
comparison with overall mortality of 26.3% (75/285) or
mortality registered in group of the surgical patients
29.5% (66/224). Because the therapeutic management in
ICU has not been changed radically in the last 10-15
years, we consider that the improvement in survival rate
was achieved by applying the OPLS technique at cases
with indication and of an optimal timing of surgery.
The main advantage of the OPLS technique is repre-
sented by repeated and progressive evacuation under
Table 10. The incidence of MODS (pre and postoperative)
and mortality after performing the OPLS technique in ret-
rospective/ prospective study.
Incidence Mortality
n % n = 16/98 16.3%
Renal dysfunction
preoperative 11 68.75
postoperative 13 81.25 6 37.5
Pulmonary dysfunction (ARDS)
preoperative 10 62.5
postoperative 12 75 8 50
Cardio-circulatory dysfunction
preoperative 7 43.75
postoperative 2 12.5 2 12.5
Table 11. The incidence of MODS (pre and postoperative)
and mortality after necrosectomy with closed abdomen and
peritoneal drainage in retrospective/prospective study.
Incidence Mortality
n % n = 50/126 39,7%
Renal dysfunction
preoperative 29 58
postoperative 34 68 16 32
Pulmonary dysfunction (ARDS)
preoperative 17 34
postoperative 19 38 22 44
Cardio-circulatory dysfunction
preoperative 15 30
postoperative 12 24 12 24
visual control of the subsequent necrosis, infections, and
toxic compounds, simultaneously with the intensive
support therapy. The combination between this technique
with the drainage of the lesser sac, the drainage of the
main collections developed in retroperitoneal subphrenic
left region or submesocolic region and the drainage of
the Douglas, makes the OPLS technique a good surgical
option in selected cases, despite the repeated trauma
(relative) on tissues at this level.
The principles underlying the OPLS technique are [12,
15,16]: it facilitates the re-exploration of the lesser sac to
the next scheduled inspection; allows an effective drain-
age of intra abdominal sepsis (surprising formation of
new collections to be drained); and virtually eliminates
the risk of developing abdominal compartment syndrome
(ACS) [10,17].
Despite these relatively good results, the probability of
failure is not fully eliminated because of some issues,
which should be taken into account: the laparostomy
provides the advantage of the easy access for drainage
and successive redebridements, but also increase the risk
of external contamination.
However, due to modern medical techniques and team
interdisciplinary cooperation (surgeon, anesthesiologist,
radiologist and microbiologist), the patient with an OPLS
may be better cared.
The comparison with other new techniques (for exam-
ple, minimal invasive techniques) in the treatment of
infected SAP proves the difficulty to choose a surgical
golden standard, generally accepted and used according
to the severity of the complications of this disease [11].
High percentage of pre and postoperative complica-
tions at patients undergoing OPLS group is correlated
with the degree of extension of the extrapancreatic ne-
crosis area.
When it comes after an episode of incontrollable sep-
sis by infected necrosis, MODS are a decisive factor of
the mortality and not the percentage or the size of the
extension of extrapancreatic necrosis [3,4,11].
Among the types of recognized pancreatic infections,
infected pancreatic necrosis is by far the most common,
the most severe and most fatal [1]. Non surgical drainage
(CT or US guided percutaneous drainage) is inadequate
in infected necrosis because of the consistency of pan-
creatic and extrapancreatic necrosis, because the percu-
taneous drainages become rapidly jammed and ineffec-
tive [18,19].
In various published studies, the authors recommend
different types of drainage: closed (aspirative drainage);
semi-closed (continuous lavage of the lesser sac); and
semi-open (OPLS) [4,9], each of them with advantages
and disadvantages. Because many deceases are due to
postoperative persistent or recurrent sepsis with devel-
opment of the MODS, ideal surgical procedure seems to
be that one which determines the lowest rate of mortality
and lowest rate of recurrent sepsis. According with these

A. HIGGINS ET AL .
14
requirements, choosing the OPLS technique during the
management of infected necrotic lesions appears fully
justified. In the prospective group was obtained an im-
provement of therapeutic results because of the patients
with extensive infected necrosis were treated by OPLS
technique.
Despite the limitation caused by a relatively small
number of cases, due to the surgical experience of op-
erators, we believe that especially at patients with in-
fected extensive extrapancreatic necrosis, which devel-
ops mainly at the lesser sac region, necrosectomy with a
complete removal of infected necrotic tissue, with lavage
and subsequent re-explorations, is better than an inter-
vention which close the abdominal wall with continuous
lavage, aspirative drainage or planned relaparotomy.
5. References
[1] M. W. Büchler, B. Gloor, C. A. Muller, H. Friess, C. A.
Seiler and W. Uhl, “Acute Necrotizing Pancreatitis:
Treatment Strategy According to the Status of Infection,”
Annals of Surgery, Vol. 232, No. 5, 2000, pp. 619-626.
[2] J. A. Harris, R. P. Jury, J. Catto and J. L. Glover, “Closed
Drainage Versus Open Packing of Infected Pancreatic
Necrosis”, Annals of Surgery, Vol. 61, No. 7, 1995, pp.
612-618.
[3] M. Besselink, T. J. Verwer, E. Schoenmaeckers, E.
Buskens, B. U. Ridwan, M. R. Visser, V. B. Nieuwen-
huijs and H. G. Gooszen., “Timing of Surgical Interven-
tion in Necrotizing Pancreatitis”, Archives of Surgery,
Vol. 142, No. 12, 2007, pp. 1194-1201.
[4] King NK, Siriwardena AK, “European Survey of Surgical
Strategies for the Management of Severe Acute Pan-
creatitis,” The American Journal of Gastroenterology,
Vol. 99, No. 4, 2004, pp. 719-728.
[5] H. W. Waclawiczek, F. Chmelizek, M. Heinerman, W.
Pimpl, H. Kaindl, P. Sungler and O. Boeckl, “Laparostoma
(Open Packing) in the Treatment Concept of Infected
Pancreatic Necroses,” Wien Klin Wochenschr, Vol. 104,
No. 15, 1992, pp. 443-447.
[6] G. Funariu, V. Binţinţan, R. Seicean and R. Scurtu, “Sur-
gical Treatment of Severe Acute Pancreatitis” Chirurgia
Bucharest, Vol. 101, No. 6, 1990, pp. 599-607.
[7] E. L. Bradley, “A Clinically Based Classification System
for Acute Pancreatitis: Summary of the International
Symposium on Acute Pancreatitis,” Archives of Surgery,
Vol. 128, No. 5, 1993, Atlanta, pp. 586-590.
[8] del C. C. Fernandez, D. W. Rattner, M. A. Makary, V. I.
A, Mostafa, D. McGrath and A. L. Warshaw, “Debride-
ment and Closed Packing for the Treatment of Necrotiz-
ing Pancreatitis,” Annals of Surgery, Vol. 228, No. 5,
1998, pp. 676-684.
[9] W. Uhl, A. Warshaw and C. Imrie, “IAP Guidelines for
the Surgical Management of Acute Pancreatitis,” Pan-
creatology, 2002, Vol. 2, No. 6, pp. 565-573.
[10] S. Connor and J. P. Neoptolemos, “Surgery for Pancreatic
Necrosis: ‘Whom, When and What’,” World Journal of
Gastroenterology, Vol. 10, No. 12, 2004, pp. 1697-1698.
[11] I. Popescu, “Management of the Severe Acute Pancreati-
tis,” Chirurgia, Vol. 101, 2006, pp. 225-228.
[12] G. Funariu, M. Suteu, G. Dindelegan, N. Maftei and R.
Scurtu, “The Indications for Celiostomy in Acute Ne-
crotizing Pancreatitis,” Chirurgia, 1990, Vol. 93, No. 6,
pp. 395-400.
[13] A. Leppäniemi, “Open Abdomen after Severe Acute Pan-
creatitis,” European Journal of Trauma and Emergency
Surgery, 2008, Vol. 34, 17-23.
[14] G. Farkas, “Pancreatic Head Mass: How can we Treat it?
Acute Pancreatitis: Surgical Treatment,” Journal of the
Pancreas, Vol. 1, No. 3, 2000, pp. 138-142.
[15] L. Edward and E. L. III Bradley, “Open Packing in In-
fected Pancreatic Necrosis,” Digestive Surgery, Vol. 997,
pp. 77-81.
[16] J. Lange, “Therapy of Acute Necrotizing Pancreatitis
with Open Packing,” Digestive Surgery, 1994, Vol. 11,
pp. 257-260.
[17] C. Bassi, G. Butturini, M. Falconi, R. Salvia, I. Frigerio,
and P. Pederzoli, “Outcome of Open Necrosectomy in
Acute Pancreatitis,” Pancreatology, 2003, Vol. 3, No. 2,
pp. 128-132.
[18] T. Bruennler, J. Langgartner, S. Lang, C. E. Wrede, F.
Klebl, S. Zierhut, S. Siebig, F. Mandraka, F. Rockmann,
B. Salzberger, S. Feuerbach, J. Schoelmerich and O.W.
Hamer, “Outcome of Patients with Acute, Necrotizing
Pancreatitis Requiring Drainage-Does Drainage Size
Matter?” World Journal of Gastroenterology, Vol. 14, No.
5, 2008, pp. 725-730.
[19] C. R. Carter, C. J. McKay and C. W. Imrie, “Percutane-
ous Necrosectomy and Sinus Tract Endoscopy in the
Management of Infected Pancreatic Necrosis: An Initial
Experience,” Annals of Surgery, Vol. 232, 2000, pp.
175-180.