An experience with 31 patients who developed major bleeding diatheses during laparotomy was reviewed. Management of the initial 14 patients was by standard hematologic replacement, completion of all facets of operation, and then closure of the peritoneal cavity, usually with suction drainage; only one patient survived. The subsequent 17 patients had laparotomy terminated as rapidly as possible to avoid additional bleeding. Major vessel injuries were repaired; ends of resected bowel were ligated; and holes in other gastrointestinal segments and the bladder were closed by purse-string sutures. One patient had a ureter ligated. Laparotomy pads (4-17) were then packed within the abdomen to effect tamponade, and the abdomen was closed under tension without drains or stomata. Following correction of the coagulopathy, the abdomen was re-explored at 15 to 69 hours in the 12 survivors. Definitive surgery then was completed: bowel resection and reanastomosis; ureter reimplantation; drains for bile, pancreatic juice, and urine; and stomata for bowel or urine diversion or decompression. Eleven of 17 patients, deemed to have a lethal coagulopathy, survived. This technique of initial abortion of laparotomy, establishment of intra-abdominal pack tamponade, and then completion of the surgical procedure once coagulation has returned to an acceptable level has proven to be lifesaving in previously non-salvageable situations.

A 20-year experience in management of 57 patients with pancreatic abscess was reviewed. Ages ranged from 17 to 91 years (average 46). Males outnumbered females 39 to 18. A prior episode of pancreatitis had been documented in 31 patients, trauma in 23, and no known cause in 3. All patients had fever (> 39~ abdominal pain and/or tenderness, and absent peristalsis. A draining wound, abdominal mass, oliguria, (< 20 ml/hr), and shock (BP < 100/60) were other prominent findings. Either leukocytosis (> 12,000/mm 3) or leukopenia (< 5,000/mm 3) was noted in 56 patients. Elevation of the serum amylase (> 200 u/100 ml) and jaundice (bilirubin > 2 mg/100 ml) were reported less frequently. Bacteremia was found in all patients not receiving parenteral antibiotics at the time blood cultures were drawn and in half despite such therapy. Plain abdominal xrays and, more recently, the computed tomography scan revealed retroperitoneal gas bubbles and/or a mass in 52 of the patients and proved to be the most useful diagnostic tests.Treatment with antibiotics alone or plus drainage led to survival in only 3 of 18. Five of 14 managed by open packing and 2 of 3 managed by distal resection with drainage died. However, when the wound following subtotal pancreatectomy was packed open, with daily pack changes, only 2 of 22 failed to survive. Deaths were primarily due to hemorrhagic (9) or septic (8) shock or some complication of these states (3).

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