Acute Necrotizing Pancreatitis: Necrosectomy versus Resection

Excerpt

There has been great improvement in knowledge of the natural course and pathophysiology of acute pancreatitis in recent decades. Treatment of severe acute pancreatitis has shifted from early surgical treatment to aggressive intensive care. In 2002, the International Association of Pancreatology (IAP) developed evidenced-based guidelines for the surgical management of acute pancreatitis.1 Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for intervention including surgery and radiological drainage, whereas patients with sterile necrosis should be managed conservatively and undergo intervention only in selected cases (e.g., fulminant acute pancreatitis, persistent necrotizing pancreatitis). The differentiation between sterile and infected necrosis is essential for the management of acute pancreatitis. Thus, all patients with pancreatic necrosis and clinical suspicion of sepsis should undergo CT-guided fine-needle aspiration for bacteriology. There is general agreement that surgery should be performed as late as possible. Because the results of pancreatic resections for acute pancreatitis were associated with high rates of morbidity and mortality, an organ-preserving approach that involves necrosectomy combined with a postoperative management concept that maximizes postoperative evacuation of retroperitoneal debris and exudates should be favored. By this, mortality of patients with acute pancreatitis dropped below 5%, and mortality rates of patients with infected necrosis who are treated surgically are as low as 10%–20% in some specialized centers.2,3 These recommendations represent the greatest evidence supporting the surgical treatment for acute pancreatitis today and are backed by several national and international guidelines.4,5 …