Indications, Timing, and Techniques in the Surgical Treatment of Acute Pancreatitis

Today acute pancreatitis still occupies one of the top positions among the so-called “benign” diseases which are, nevertheless, associated with high morbidity and mortality. Although 80–90% of cases of acute pancreatitis are of the mild type (MAP), i.e., they are self-limiting, spontaneously resolving within 5–7 days with minimal treatment (“a 1-week disease”), 10–20% of patients develop necrotizing severe acute pancreatitis (SAP), which carries a mortality of up to 30% [1, 2]. Treatment of SAP has been debated since the end of the 1800s, contrasting a conservative medical “wait and see” approach on the one hand against aggressive surgery on the other. At the end of the 1980s and for the first few years of the 1990s the following axiom ruled: “Edematous pancreatitis: medical therapy; necrotic pancreatitis: immediate surgery” [3, 4]. However, the unsettling results and high mortality rates that resulted from treatment following this paradigm soon led to debate about how appropriate it was. In the following years, the wider availability of CT scans with contrast and the Balthazar score made it possible to identify the extent of the necrosis and to apply a grading system to the severity of the illness [5]; furthermore, monoparametric prognostics (CRP, procalcitonin, IL- 6) and multiparametric scores (Ranson, Glasgow, Apache II) were introduced, improving clinicians’ ability to predict the severity of the illness.