SURGICAL STRATEGIES IN ACUTE-PANCREATITIS

The most important diagnostic step in the management of patients with acute pancreatitis is to discriminate between interstitial-edematous a nd necrotizing pancreatitis. Measurement of C-reactive protein or PMN- elastase is useful in detecting the necrotizing course of acute pancre atitis. While patients with acute edematous pancreatitis can be treate d on a regular ward, patients with a necrotizing course should be trea ted in the ICU. Surgical decision-making in necrotizing pancreatitis s hould be based on the extent of necroses found by contrast-enhanced CT , and on the development of septic signs due to bacterial infection of the necroses. Information about the latter can be obtained by a bedsi de ultrasound-guided fine needle aspiration and bacteriological examin ation of the aspirate. Patients with no organic complications and with focal necrosis should be treated conservatively, while patients with persistent organic insufficiencies or progressive multiple organ failu re despite maximum intensive care are candidates for surgical therapy. The procedure of choice in necrotizing pancreatitis is the careful re moval of necrotic tissue (necrosectomy) followed and supplemented by a postoperative regimen for the continuous evacuation of further necrot ic debris. Hospital mortality rate has been reduced to less than 20% b y this procedure.