Eighteen consecutive patients with sepsis due to surgically confirmed peripancreatic necrosis extending diffusely into the retroperitoneal fat were treated in our hospital from 1980 to 1987. Management consisted of early retroperitoneal debridement of necrotic tissue and drainage through lumbar incisions. Enteral nutrition was implemented in all patients 3-8 days after their first surgery. A total of 40 reoperations were required--an average of 2.6 per patient. Complications included respiratory failure (17), renal failure (4), gastrointestinal bleeding (4), retroperitoneal bleeding (1), and gastrointestinal fistulas (6). Four (22%) of the 18 patients died; the major cause of death was multiple organ failure secondary to sepsis. Before 1980, all patients with severe pancreatitis treated in our hospital died, despite the use of different management techniques. The use of the extraperitoneal route for early debridement of necrotic tissue and to avoid contamination of the peritoneal cavity has substantially reduced the mortality associated with peripancreatic necrosis in our hospital. The mortality in this series of patients (22%) compares very favorably with that reported in studies of similar patients.

SummaryIn recent times our understanding of metabolism at the biochemical and subcellular level has increased. It is now apparent that an understanding of the causes and mechanism of the inflammatory response to sepsis is vital to the management of this condition. The systemic inflammatory response in sepsis disrupts the normal homeostatic processes and can progress to multiple organ failure and death.Increased metabolic rate as a result of sepsis causes a characteristic hypocaloric and hypoproteinaemic malnutrition. Specific amino acids are necessary for the synthesis of proteins and vasoactive peptides and for the functioning of macrophages and leucocytes. In addition, arginine, glutamine, omega-6-fatty-acids and nucleotides are required for adequate immune function. Thus, adequate nutritional support can greatly influence outcome in patients with sepsis.Since the adverse sequelae of sepsis result from the neuroendocrine inflammatory response, nonsteroidal anti-inflammatory drugs have therapeutic potential in this condition. In the future, monoclonal antibodies to bacterial endotoxins are expected to limit the inflammatory response to endotoxins produced by Gram-negative bacteria.