Severe Acute Pancreatitis due to Gallstones Controlled by Multimodal Therapy Including Open Necrosectomy

Abstract

A 65-year-old man was hospitalized with sudden onset of abdominal pain that developed while he was on a business trip. He was diagnosed as having acute pancreatitis due to gallstones, which was initially mild, but became severe by third day of hospitalization. On the 51st day of hospitalization, we found an abscess around the right iliopsoas muscle and his hemodynamic and respiratory status became unstable. Hence, we performed emergency open necrosectomy on the same day. After the operation, he required multimodal therapy, including continuous hemodiafiltration, artificial respiration, and peritoneal lavage. On the 74th and 79th days after the operation, he developed hemorrhagic shock caused by intraperitoneal bleeding. We saved his life both times by successful intervention. At this time, we also observed fistulas in the jejunum and transverse colon, which were effectively treated by drainage and ileostomy. After a prolonged rehabilitation period, he was moved to another hospital on the 335th day after the operation. In recent years, reports have highlighted the importance of using a step-up approach when treating severe acute pancreatitis. On the other hand, our case shows that open necrosectomy is a valid approach for patients who require immediate treatment. Note, however, that expertise is needed for treating complications by this method.