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Damage Control Pancreatic Débridement: Salvaging the Most Severely Ill

Thomas K Maatman, Alexandra M Roch, Eugene P Ceppa, Michael G House, Attila Nakeeb, C Max Schmidt, R Michael Cournoyer, Katherine M Wehlage, Nicholas J Zyromski

Introduction Damage control laparotomy is a widely accepted practice in trauma surgery. We applied this approach selectively to severely ill patients requiring open pancreatic débridement. We sought to evaluate outcomes associated with this novel, staged approach to operative pancreatic débridement. Methods Retrospective review evaluating 75 consecutive patients (12 DCD, 63 single-stage debridement) undergoing open pancreatic débridement by a single surgeon (2006-2016). Damage control débridement was compared to single staged débridement only as a point of reference and not to evaluate the technique as potentially superior. Results Patients treated by damage control débridement were more severely ill globally with increased preoperative organ failure (83% DCD vs. 43% SSD), intensive care unit admission (83% vs. 48%), and mean APACHE II (12.0 vs. 7.3). Indications for damage control débridement included: hemodynamic compromise (n=4), medical coagulopathy (n=4), or a combination (n=4). Six of 12 damage control débridement patients required three or more débridements prior to definitive abdominal closure (mean number of total débridements=2.6; range 2-4). Length of stay (43.8 vs. 17.1 days) and intensive care unit stay (20.8 vs. 5.9 days) was longer in damage control débridement patients. However, readmission (42% vs. 41%) and repeat intervention (58% vs. 33%; endoscopic: 17% vs. 11%; percutaneous drain: 42% vs. 19%; repeat operation after abdominal closure: 0% vs. 13%) were similar. Overall mortality was 2.7%; mortality was similar between damage control débridement (8%) and single staged débridement (2%). Conclusions Despite more severe acute illness, necrotizing pancreatitis patients treated with damage control débridement had similar morbidity and mortality as those undergoing elective single stage pancreatic débridement. Damage control débridement is an effective technique with which to salvage severely ill necrotizing pancreatitis patients.