Surgical strategies in acute pancreatitis

The most important diagnostic step in the management of patients with acute pancreatitis is to discriminate between interstitial-edematous and necrotizing pancreatitis. Measurement of C-reactive protein or PMN-elastase is useful in detecting the necrotizing course of acute pancreatitis. While patients with acute edematous pancreatitis can be treated on a regular ward, patients with a necrotizing course should be treated in the ICU. Surgical decision-making in necrotizing pancreatitis should be based on the extent of necroses found by contrast-enhanced CT, and on the development of septic signs due to bacterial infection of the necroses. Information about the latter can be obtained by a bedside ultrasound-guided fine needle aspiration and bacteriological examination of the aspirate. Patients with no organic complications and with focal necrosis should be treated conservatively, while patients with persistent organic insufficiencies or progressive multiple organ failure despite maximum intensive care are candidates for surgical therapy. The procedure of choice in necrotizing pancreatitis is the careful removal of necrotic tissue (necrosectomy) followed and supplemented by a postoperative regimen for the continuous evacuation of further necrotic debris. Hospital mortality rate has been reduced to less than 20% by this procedure.