Techniques of surgical treatment

The surgical treatment of necrotizing pancreatitis has three major goals: (i) evacuation of necrotic tissue and exudate which releases toxic compounds into the circulation and accounts for remote organ failure, (ii) prevention of complications such as infection and pancreatic abscess by removing pancreatic necrosis, and (iii) preservation of pancreatic tissue which is still vital (this strongly influences the quality of long-term results concerning endo- and exocrine pancreatic function). A variety of different approaches have been advocated, ranging from conservative non-resecting methods to aggressive extensively resecting procedures.

As surgical treatment centers on debridement of necrotic tissue, simple peritoneal dialysis cannot be considered adequate as its effects are restricted to the abdominal cavity and do not address the necrotizing process in the retroperitoneal space. Controlled trials have shown no reduction in overall mortality of severe acute pancreatitis.

Pancreatic resection modalities—partial or total pancreaticoduodenectomy—aim at radical removal of the gland. Even in patients with macroscopically total pancreatic necrosis, pancreatectomy is rarely justified as in many cases only the superficial areas of the gland are necrotic. This type, known as 'surface pancreatitis', can easily be mistaken intraoperatively for total pancreatic necrosis. The removal of still viable pancreatic parenchyma and healthy duodenum, stomach, and biliary tracts poses additional stress on the critically ill patient. Therefore resecting surgical modalities carry the risk of overtreatment, are linked to high postoperative and increased late morbidity, and have been abandoned.

The most appropriate surgical procedure for necrotizing pancreatitis is the careful removal of necrosis in combination with an additional technique to provide further evacuation of infected peripancreatic exudates and to promote further debridement. This change in intraoperative management has decreased mortality from above 80 per cent to about 20 per cent. Three competitive techniques have been introduced to deal with the peripancreatic space after necrosectomy ( T§Me..5).

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Table S Incidence of acute pancreatitis

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