THE ROLE OF SURGERY IN THE MAJOR EARLY COMPLICATIONS OF SEVERE ACUTE-PANCREATITIS

The early complications of severe acute pancreatitis may constitute a dramatic clinical dilemma in the first 2 weeks of the disease, when th e surgical approach is made even more difficult by failure to define t he precise extent of the necrotic component of the disease. Moreover, the surgical indication itself is not always based on clear guidelines to which the clinician can refer, and this is due to factors of two t ypes: (i) the intrinsic complexity of the pancreatitis syndrome in its early toxic stages and (ii) the difficulty in understanding the relev ant information reported in the literature in this connection, which i s often incomplete and based on confused terminology. While the surgic al indication is universally accepted in the case of infection of the necrotic tissue (an event, however, which is by no means frequent in t he early stages of severe pancreatitis), the development of multi-orga n failure despite adequate intensive care is a potential indication wh ich not all specialists go along with, at least not as regards the ide al timing of the intervention. Other surgical indications which have e merged are evidence of complete rupture of the main pancreatic duct an d the presence of very extensive sterile necrosis. As things stand at present, however, we are witnessing a general tendency to postpone sur gery, since delayed surgery is associated with a lower incidence of co mplications than is the case with early surgery. If, as is known, the role of surgery is aimed mainly at the treatment of superinfections an d severe multi-organ failures, targeted antibiotic prophylaxis and ear lier, more complete anti-enzymatic therapy may, as suggested by a numb er of pilot studies, offer a promising alternative to invasive procedu res which are sometimes risky, though indispensable, in an attempt to save patients who would otherwise have no chance of survival.