New approaches in surgical management of severe acute pancreatitis

Despite many prospective randomized clinical studies a specific pharmacothe rapy for severe acute pancreatitis is not in sight. To date, the only possi bility to influence the prognosis of this severe illness is early diagnosis and prevention of intra- and extrapancreatic necrosis and its subsequent i nfection. In severe necrotizing pancreatitis the incidence of infected necr osis amounts to 40-70% of all patients within 3 weeks. Thereby, the clinica l picture often varies to large extent. Ultrasonographically or computertom ography-guided fine-needle aspiration (FNAC) is a fast and reliable techniq ue for diagnosis with an overall sensitivity of 88% and specificity of 90%. This method should however not be applied too early in the course of necro tizing pancreatitis. Since infection of pancreatic necrosis determines sign ificantly the prognosis of disease, various studies have assessed the effic acy of prophylactic antibiotic treatment in patients. Three prospective ran domized studies have shown that prophylaxis significantly minimizes septic complications, only in one study, however, the mortality rate could be impr oved. Although randomized studies are still mandatory to resolve the contro versy, it seems justified to recommend prophylaxis with antibiotics which a re capable of penetrating the pancreatic tissue and juice; Sterile necrosis should be treated conservatively, with prophylactic antibiotic treatment f or; as long as possible. Only if patients worsen despite intensive care med icine, surgical debridement should be considered. In contrast, in patients with infected necrosis immediate surgery is in most cases mandatory. Althou gh in one prospective study conservative treatment did not lead to an enhan ced mortality rate, possible delay of surgical treat ment may endanger the patient. In order to improve the prognosis of the disease, timely and adequ ate treatment in specialized units provides the best chances for a good pro gnosis whereby the severely ill patient should not be treated according to a scheme but to his/her individual needs.