Indication for surgery in acute necrotizing pancreatitis

Abstract

Management of acute necrotizing pancreatitis has changed significantly over the past few years. Early management is nonsurgically and solely supportive. Today, more patients survive the early phase of severe pancreatitis owing to improvements in intensive care medicine. Pancreatic infection is the major risk factor with regard to morbidity and mortality in the late phase of severe acute pancreatitis. Whereas early surgery and surgery for sterile necrosis can only be recommended in selected cases, pancreatic infection is a well-accepted indication for surgical treatment. Surgery should ideally be postponed until 4 weeks after the onset of symptoms as the necrotic tissue is well demarcated at that time. Four surgical techniques can be performed with comparable results regarding mortality: necrosectomy combined with (1) open packing, (2) planned staged relaparotomies with repeated lavage, (3) closed continuous lavage of the retroperitoneum, and (4) closed packing. However, closed continuous lavage of the retroperitoneum and closed packing seem to be associated with a lower morbidity compared with the other two approaches. Advances in radiologic imaging, new developments in interventional radiology, and other minimal-access interventions have revolutionized the management of many surgical conditions over the past few decades. However, minimally invasive surgery and interventional therapy for infected necrosis should be limited to specific indications in patients who are critically ill and otherwise unfit for conventional surgery. Open surgical debridement is the gold standard for treatment of infected pancreatic and peripancreatic necrosis. © 2009 Springer-Verlag Berlin Heidelberg.