[Fulminant pancreatitis--surgical point of view]

Today, treatment of acute pancreatitis is mainly conservative and surgery is on the retreat. Infection of pancreatic necrosis is still the main risk factor of morbidity and mortality in the course of necrotizing disease. A prophylactic treatment with antibiotics can reduce both infectious complications and mortality. Thus, antibiotics should be administered in severe pancreatitis. If pancreatic infection is suspected, fine needle aspiration should be performed. Today, infected pancreatic necrosis is a well accepted indication for surgery. Aim of the surgical procedure is to remove the septic focus by debridement of the infected pancreatic and peripancreatic necrosis. The optimal timepoint for the surgical intervention is the 3rd to 4th week after onset of the disease. At that time, necrotic tissue is well demarcated. Therefore bleeding complications and removal of vital tissue can be avoided. Today, surgical procedures should combine the necrosectomy with a postoperative method to continuously remove necrosis and debris. This is the case with the following two techniques, the postoperative continuous lavage and the closed packing. In contrast, sterile necrosis is usually treated conservatively. Fulminant acute pancreatitis is a rare subgroup of acute pancreatitis, characterized by a rapidly progressive multiple organ failure in the first days following the onset of the disease with a high probability of death despite ICU therapy. There is poor outcome with both, surgical and conservative therapies. Thus, surgery should only be peformed as an ultima ratio.