YALE JOURNAL OF BIOLOGY AND MEDICINE 70 (1997), pp. 109-117. Copyright © 1997. All rights reserved. Surgical Treatment of Necrotizing Pancreatitis W. Uhl and M.W. Buchlera Department of Visceral and Transplantation Surgery, University of Berne, Switzerland (Received June 28, 1996; accepted October 14, 1996) Surgical treatment in patients with severe acute pancreatitis is still a controver- sial subject, ranging from sole conservative to an aggressive approach. This arti- cle gives an overview of the literature with regard to indications for surgery, tim- ing and techniques of operative treatment concepts in severe acute pancreatitis with special attention to the recommended necrosectomy and closed continuous lavage of the involved retroperitoneum. Taking into account recent findings from microbiological data we have developed a new algorithm in patients with acute pancreatitis. All patients with proven acute necrotizing pancreatitis receive an antibiotic therapy for 2 weeks beside the intensive care measures. So far only one third (33 percent) had infected pancreatic necroses in the 3rd week of the onset of the disease and were managed surgically. The delay resulted in optimal surgical conditions for necrosectomy and a mortality rate of 9 percent. This new concept and therapeutic approach with the early suitable antibiotic therapy in patients with proven necrotizing pancreatitis is recommended to (1) decrease the infection rate and (2) delay surgical intervention to the 3rd week of the disease with optimal surgical conditions. It seems that only patients with proven infected pancreatic necroses are candidates for surgical intervention. INTRODUCTION Acute pancreatitis can be classified histologically as interstitial-edematous or necro- tizing inflammation of the pancreatic gland, and the clinical course in patients with acute pancreatitis varies from a mild, transitory illness to a rapidly fatal disease [1, 2]. Clinical and experimental observations have shown that in the early stage of severe acute pancrea- titis biologically active compounds are released into ascitic fluids and systemic circulation [3, 4]. Patients who die within the first week due to necrotizing pancreatitis suffer cardio- vascular, pulmonary, and renal complications which determine the clinical course. Because of improvement in intensive care therapy, and particularly with the early central venous pressure-adjusted fluid replacement, hardly any patient with acute pancreatitis dies within this early phase of the disease. Septic complications prevail in the later stage of necrotizing pancreatitis, and, nowadays, local and systemic septic complications are the most frequent cause of death in severe acute pancreatitis [5, 6, 7]. Clinical management of acute pancreatitis is based on the observation that most patients have a mild, self-limiting disease [8]. However, there are appreciable uncertain- ties with regard to the therapeutic schedule, since specific and effective pharmacotherapy is not available, and the effectiveness of surgical treatment of necrotizing pancreatitis has so far not been substantiated by controlled prospective clinical data. Undoubtedly, in patients with acute pancreatitis and local septic complications following bacterial infec- tion of necrotic material, surgical therapy has proved superior to the conservative treat- ment in the past [8, 9]. aTo whom all correspondence should be addressed: Professor M.W. Biichler, M.D., Department for Visceral and Transplantation Surgery, University Hospital of Berne, CH-3010 Berne, Switzerland. Tel.: 41-31-632-21-11; Fax: 41-31-632-97-23; E-mail: markus.buechler@insel.ch bAbbreviations: ICU, intensive care unit; CT, computed tomography. 109