[Surgical therapy of severe acute pancreatitis]

There is some evidence that the incidence of acute pancreatitis is increasing worldwide. Improved treatment concepts, especially in the severe course of the disease, have significantly reduced formerly high mortality. According to the different clinical courses it is of the utmost importance for the therapeutic approach to this disease to differentiate between mild (morphologically characterized as edema) and severe (intra- and extrapancreatic necroses) as early as possible. In this respect, contrast-enhanced CT scanning and the determination of so-called necrosis indicating parameters (e.g. C-reactive protein) have been established as the "gold-standard". While patients with acute edematous pancreatitis are successfully treated in a normal ward, patients with a proven necrotizing course of the disease should undergo intensive monitoring and maximum intensive care therapy in the ICU. Additionally, these latter patients should receive antibiotics which are capable of penetrating the pancreas and the pancreatic necroses in bactericidal concentrations. It seems more and more evident that only patients under this treatment regimen who develop infected pancreatic necrosis and sepsis are candidates for surgical intervention. Infected pancreatic necrosis can be easily diagnosed with a high level of safety and reliability by fine needle puncture and aspiration of pancreatic necrosis and fluid collections under imaging-guided procedures. Patients with sterile necrosis respond in most cases to intensive care therapy and in these patients the indication for surgery will be only exceptional. Surgery should be performed as late as possible to ensure sufficient demarcation of the necroses. In our experience the best surgical treatment modality for infected pancreatic necrosis is necrosectomy combined with postoperative continuous local lavage of the retroperitoneum. Mortality of severe acute pancreatitis has been reduced under this treatment concept to below 10%.