Operative vs. Nonoperative therapy in necrotizing pancreatitis

Anecdotal and uncontrolled recommendations for programmatic surgical intervention in necrotizing pancreatitis are gradually being replaced by nonoperative approaches as prospective natural history information becomes available. In patients with sterile pancreatic necrosis, nonoperative managements has now been shown to result in a mortality rate equal or better to surgical debridement. Moreover, since surgical debridement of sterile pancreatic necrosis has not been shown to prevent or ameliorate co-existing organ failure, and given that secondary infection of sterile necrosis occurs as a result of operative debridement in 25% of cases and results in a trebling of mortality risk, it is becoming increasingly clear that surgical debridement in sterile necrotizing pancreatitis will become the exception rather than the rule. However, surgical debridement and drainage remains the preferred approach for infected pancreatic necrosis despite occasional anecdotal reports of successful management by transcutaneous or endoscopic means. While the optimal post-surgical technique of drainage remains controversial, a selective approach is reasonable, with the choice between closed drainage, lesser sac lavage, or schedule re-explorations being based upon extent of the necrotic process.