Technique and outcome of surgical therapy 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 necroses indicating parameters in the serum, like CRP and PMN-elastase are 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 of disease should be treated in the intensive-care unit. Patients with biliary acute pancreatitis should be examined by ERCP with the performance of a papillotomy with stone removal in case of impacted ampullary stones within 24 hours. Surgical decision-making in patients with necrotizing pancreatitis should be based on the development of septic signs due to infected pancreatic necrosis. The information about infected pancreatic necrosis can be easily obtained by a bedside ultrasound-guided fine needle aspiration and bacteriological examination of the aspirate [gram stain plus culture]. Patients without organ complications and with focal necroses should be treated conservatively while patients with persisting organ insufficiencies or progressive multiple organ failure despite maximum intensive care measures 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. For this postoperative therapeutical concept three comparable procedures are available today, the closed continuous lavage, the 'open packing technique' and the management by planned, staged re-laparotomies. Hospital mortality in severe acute pancreatitis has been reduced to less than 15% by these procedures in experienced hands.