Modern phase-specific management of acute pancreatitis

The management of acute necrotizing pancreatitis has changed significantly over the past years. In contrast to the early surgical intervention of the past, there is now a strong tendency towards a more conservative approach. Initially, severe acute pancreatitis is characterized by the systemic inflammatory response syndrome. Early management is non-surgically and solely supportive. A specific treatment still does not exist. In cases of necrotizing disease, prophylactic antibiotics should be applied to reduce late septic complications. Today, more patients survive the first phase of severe pancreatitis due to improvements of intensive care medicine, thus increasing the risk of later sepsis. Pancreatic infection is the major risk factor with regard to morbidity and mortality in the second 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 in the second phase of the disease. Surgery should ideally be postponed until 4 weeks after the onset of symptoms, as necrosis is well demarcated at that time. Three surgical techniques can be performed with comparable results regarding mortality: necrosectomy combined with the (1) open packing technique, (2) planned staged relaparotomies with repeated lavage, or (3) closed continuous lavage of the retroperitoneum. However, the latter method seems to be associated with the lowest morbidity compared to the other approaches.