Necrotizing pancreatitis: Indications for surgery and surgical techniques

The term, “acute pancreatitis”, covers in terms of clinical, pathological, biochemical and bacteriological data, different entities in regard to the natural course of the disease. Interstitial edematous pancreatitis and necrotizing pancreatitis are the most frequent clinical manifestations; pancreatic abscess and postacute pseudocyst are late complications, mostly of necrotizing pancreatitis, developing after 3–5 weeks. The first choice of treatment is non-surgical management, even in patients with a severe complicated course of the disease. Patients who develop surgical acute abdomen, clinical sepsis syndrome, shock syndrome, or a severe type of mechanical or adynamic ileus must be treated surgically. Patients who do not respond to maximum intensive care measures for pulmonary, renal, cardiocirculatory, and metabolic dysfunction are candidates for surgical treatment, despite the possibility of sterile necrosis causing systemic complications. Surgical treatment is indicated in patients with infected necrosis, debridement and continuous closed lavage or open packing with re-operation being the most accepted treatment protoclos. When necrosectomy/debridement plus closed postoperative lavage was employed as a standard surgical treatment, hospital mortality was less than 20% in patients with infected necrosis as well as those with sterile necrosis. In pancreatic abscess and postacute pseudocyst, the treatment of first choice is intervention via ultrasound- or CT-guided percutaneous puncture and drainage of the abscess cavity. However, the majority of patients with a pancreatic abscess, treated interventionally, are candidates for a surgical drainage procedure because the interventional drainage fails to control the sepsis rapidly.