Indications, Timing, and Techniques in the Surgical Treatment of Acute Pancreatitis

  • Walter Siquini
  • Gianluca Guercioni
  • Raffaella Ridolfo
  • Aroldo Fianchini
Part of the Updates in Surgery book series (UPDATESSURG)


Today acute pancreatitis still occupies one of the top positions among the so-called “benign” diseases which are, nevertheless, associated with high morbidity and mortality. Although 80–90% of cases of acute pancreatitis are of the mild type (MAP), i.e., they are self-limiting, spontaneously resolving within 5–7 days with minimal treatment (“a 1-week disease”), 10–20% of patients develop necrotizing severe acute pancreatitis (SAP), which carries a mortality of up to 30% [1, 2]. Treatment of SAP has been debated since the end of the 1800s, contrasting a conservative medical “wait and see” approach on the one hand against aggressive surgery on the other. At the end of the 1980s and for the first few years of the 1990s the following axiom ruled: “Edematous pancreatitis: medical therapy; necrotic pancreatitis: immediate surgery” [3, 4]. However, the unsettling results and high mortality rates that resulted from treatment following this paradigm soon led to debate about how appropriate it was. In the following years, the wider availability of CT scans with contrast and the Balthazar score made it possible to identify the extent of the necrosis and to apply a grading system to the severity of the illness [5]; furthermore, monoparametric prognostics (CRP, procalcitonin, IL- 6) and multiparametric scores (Ranson, Glasgow, Apache II) were introduced, improving clinicians’ ability to predict the severity of the illness.


Acute Pancreatitis Systemic Inflammatory Response Syndrome Severe Acute Pancreatitis Pancreatic Necrosis Abdominal Compartment Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bradley EL, Allen K (1991) A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis. Am J Surg 161:19CrossRefPubMedGoogle Scholar
  2. 2.
    Baron TH, Morgan DE (1999) Acute necrotizing pancreatitis. N Engl J Med 340:1412CrossRefPubMedGoogle Scholar
  3. 3.
    Ranson JH (1984) Acute pancreatitis: pathogenesis, outcome and treatment. Clin Gastroenterol 13:843PubMedGoogle Scholar
  4. 4.
    Steinberg W, Tenner S (1994) Acute pancreatitis. N Engl J Med 330:1198CrossRefPubMedGoogle Scholar
  5. 5.
    Balthazar EJ, Ranson JH, Naidich DP et al (1985) Acute pancreatitis: prognostic value of CT. Radiology 156:767PubMedGoogle Scholar
  6. 6.
    Bradley EL (1993) A clinical based classification system for acute pancreatitis: Summary of the International Symposium on Acute Pancreatitis, Atlanta, Georgia, 1992. Arch Surg 128:586PubMedGoogle Scholar
  7. 7.
    Ratary MG, Connor S, Criddle DN et al (2004) Acute pancreatitis and organ failure: pathophysiology, natural history and management strategies. Curr Gastroenterol Rep 6:99CrossRefGoogle Scholar
  8. 8.
    Büchler MW, Gloor B, Müller CA et al (2000) Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 232:619CrossRefPubMedGoogle Scholar
  9. 9.
    Bassi C (1994) Infected pancreatic necrosis. Int J Pancreatol 16:1PubMedGoogle Scholar
  10. 10.
    Fernandez del Castillo C, Rattner DW, Herferth C et al (1993) Acute pancreatitis. Lancet 342:475CrossRefPubMedGoogle Scholar
  11. 11.
    Heinrich S, Schäfer M, Rousson V et al (2006) Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg 243:154CrossRefPubMedGoogle Scholar
  12. 12.
    Werner J, Uhl W, Büchler MW (2004) Acute pancreatitis. In: Cameron JL (ed) Current surgical therapy. Mosby, St Louis, p 459Google Scholar
  13. 13.
    Whang EE (2006) Acute pancreatitis. In: Greenfield’s surgery: scientific principles and practice, 4th edn. Lippincott Williams & Wilkins, Philadelphia, p 840Google Scholar
  14. 14.
    Nathens AB, Curtis JR, Beale RJ et al (2004) Management of the critically ill patient with severe acute pancreatitis. Crit Care Med;32:2524CrossRefPubMedGoogle Scholar
  15. 15.
    Mayumi T, Takada T, Kawarada Y et al (2006) Management strategy for acute pancreatitis in the Japan Guidelines. J Hepatobiliary Pancreat Surg 13:61CrossRefPubMedGoogle Scholar
  16. 16.
    Banks PA, Freeman LM (2006) Practice guidelines in acute pancreatitis. Am J Gastroenterol 101:2379CrossRefPubMedGoogle Scholar
  17. 17.
    Beger HG, Bittner R, Block S et al (1986) Bacterial contamination of pancreatic necrosis: a prospective clinical study: Gastroenterology 91:433PubMedGoogle Scholar
  18. 18.
    Gianotti L, Munda R, Alexander JW (1992) Pancreatitis-induced microbial translocation: a study of the mechanism. Res Surg 4:87Google Scholar
  19. 19.
    Ammori BJ, Leeder PC, King RF et al (1999) Early increase in intestinal permeability in patients with severe acute pancreatitis: correlation with endotoxemia, organ failure, and mortality. J Gastrointest Surg 3:252CrossRefPubMedGoogle Scholar
  20. 20.
    Teerenhovi O, Nordback I, Eskola J (1989) High volume lesser sac lavage in acute necrotizing pancreatitis. Br J Surg 76:370CrossRefPubMedGoogle Scholar
  21. 21.
    Ihse I, Evander A, Gustafson I et al (1986) Influence of peritoneal lavage on objective prognostic signs in acute pancreatitis. Ann Surg 204:122CrossRefPubMedGoogle Scholar
  22. 22.
    Mayer AD (1985) Controlled clinical trial of peritoneal lavage for the treatment of severe acute pancreatitis. N Engl J Med 312:399PubMedCrossRefGoogle Scholar
  23. 23.
    Nordback I, Paajanet H, Sand J (1997) Prospective evaluation of a treatment protocol in patients with severe acute necrotizing pancreatitis. Eur J Surg 163:357PubMedGoogle Scholar
  24. 24.
    Kalfarentzos FE, Kehagias J, Kakkos SK et al (1999) Treatment of patients with severe acute necrotizing pancreatitis based on prospective evaluation. Hepatogastroenterology 46:3249PubMedGoogle Scholar
  25. 25.
    Mier J, Leon EL, Castillo A et al (1997) Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg 173:71CrossRefPubMedGoogle Scholar
  26. 26.
    Beger HG, Büchler M, Bittner R et al (1988) Necrosectomy and postoperative local lavage in necrotizing pancreatitis. Br J Surg 75:207CrossRefPubMedGoogle Scholar
  27. 27.
    Tsiotos GG, Luque-de Leon E, Soreide JA et al (1998) Management of necrotizing pancreatitis by repeated operative necrosectomy using a zipper technique. Am J Surg 175:91CrossRefPubMedGoogle Scholar
  28. 28.
    Beger HG (1991) Operative management of necrotizing pancreatitis and continous closed postoperative lavage of the lesser sac. Hepatogastroenterology 38:129PubMedGoogle Scholar
  29. 29.
    Draganov P, Forsmark CE (2005) Disease of the pancreas. In: ACP Medicine. Gastroenterology 5. WebMB, p 689. Available at: www.acponline.comGoogle Scholar
  30. 30.
    Schein M (2005) Acute pancreatitis. In: Schein M, Rogers PM (eds) Schein’s common sense emergency abdominal surgery. Springer, Berlin Heidelberg New York, p 154CrossRefGoogle Scholar
  31. 31.
    Banks PA (1997) Practice guidelines in acute pancreatitis. Am J Gastroenterol 92:377PubMedGoogle Scholar
  32. 32.
    Gerzof SG, Banks BA, Robbins AH et al (1987) Early diagnosis of pancreatic infection by computed tomography-guided aspiration. Gastroenterology 93:1315PubMedGoogle Scholar
  33. 33.
    Rau B, Pralle U, Mayer JM et al (1998) Role of ultrasonographically guided fine-needle aspiration cytology in the diagnosis of infected pancreatic necrosis. Br J Surg 85:179CrossRefPubMedGoogle Scholar
  34. 34.
    Garg PK, Khanna S, Bohidar NP et al (2001) Incidence, spectrum and antibiotic sensitivity pattern of bacterial infection among patients with acute pancreatitis. J Gastroenterol Hepatol 16:1055CrossRefPubMedGoogle Scholar
  35. 35.
    Neoptolemos JP, Carr-Locke DL, London NJ et al (1988) Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones. Lancet 2:979CrossRefPubMedGoogle Scholar
  36. 36.
    Novak A, Nowakowska E, Marek TA et al (1995) Final results of the prospective, randomized, controlled study on endoscopic sphincterotomy versus conventional management in acute biliary pancreatitis. Gastroenterology 108:A380Google Scholar
  37. 37.
    Fan ST, Lai EC, Mok FP et al (1993) Early treatment of acute biliary pancreatitis by endoscopic papillotomy. N Engl J Med 328:228CrossRefPubMedGoogle Scholar
  38. 38.
    Folsch UR, Nitsche R, Ludtke R et al (1997) Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. N Engl J Med 336:237CrossRefPubMedGoogle Scholar
  39. 39.
    Fernandez del Castillo C, Rattner DW, Makary MA et al (1998) Debridement and closed packing for the treatment of necrotizing pancreatitis. Ann Surg 228:676CrossRefPubMedGoogle Scholar
  40. 40.
    Hungness ES, Robb BW, Seeskin C et al (2002) Early debridement for necrotizing pancreatitis: is it worthwhile? J Am Coll Surg 194:740CrossRefPubMedGoogle Scholar
  41. 41.
    Hartwig W, Maksan S, Foitzik T et al (2002) Reduction in mortality with delayed surgical therapy of severe pancreatitis. J Gastrointestinal Surg 6:481CrossRefGoogle Scholar
  42. 42.
    Nordback I, Sand J, Saaristo R et al (2001) Early treatment with antibiotics reduces the need for surgery in acute necrotizing pancreatitis: a single center randomized study. J Gastrointest Surg 5:113CrossRefPubMedGoogle Scholar
  43. 43.
    Besselink MG, Verwer TJ, Schoenmaeckers EJ et al (2007) Timing of surgical intervention in necrotizing pancreatitis. Arch Surg 142:1194CrossRefPubMedGoogle Scholar
  44. 44.
    Mofidi R, Lee AC, Madhavan KK et al (2007) Prognostic factors in patients undergoing surgery for severe necrotizing pancreatitis. World J Surg 31: 2002CrossRefPubMedGoogle Scholar
  45. 45.
    Rodriguez JR, Razao AO, Targarona J et al (2008) Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 274:294CrossRefGoogle Scholar
  46. 46.
    Sarr MG, Tsiotos GG (2004) Necrosectomia per pancreatite acuta necrotica. In: Baker RJ, Fischer JE (eds) Mastery in chirurgia. Verduci, Roma, p 1305Google Scholar
  47. 47.
    Teerenhovi O, Nordback I, Isolauri J (1988) Influence of pancreatic resection on systemic complication in acute pancreatitis. Br J Surg 75:793CrossRefPubMedGoogle Scholar
  48. 48.
    Kingsnorth A, O’Reilly D (2006) Acute pancreatitis. BMJ 332:1072CrossRefPubMedGoogle Scholar
  49. 49.
    Besselink MG, De Brujin MT, Rutten JP et al (2006) Dutch Acute Pancreatitis Study Group. Surgical intervention in patients with necrotizing pancreatitis. Br J Surg 93:593CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Italia 2009

Authors and Affiliations

  • Walter Siquini
    • 1
  • Gianluca Guercioni
    • 2
  • Raffaella Ridolfo
    • 2
  • Aroldo Fianchini
    • 2
  1. 1.Department of Surgery, Ospedali Riuniti University HospitalPolytechnic University of MarcheAnconaItaly
  2. 2.Division of General SurgeryC. e G. Mazzoni County HospitalAscoli PicenoItaly

Personalised recommendations