The Principles of Surgical Treatment of the Pancreatic Necrosis

Abstract

The management of the pancreatic necrosis caused by acute pancreatitis is emphasized more these days. The reason for this is 5 to 10 times increased mortality by necrosis which itself is seen only in 5-20% of the acute pancreatitis cases. More important is that conservatively managed infected necrosis yields to death in almost 100% of cases. Early diagnosis and correct management is important.

Computerized tomography is the main tool of diagnosis. Necrotic areas do not take the contrast material. Computerized tomography has a false positivity rate of lower than 3%.

During the management of the pancreatic necrosis, one must consider whether the necrosis is infected or not, the extent of the necrosis and other complications (infected pseudocyst pancreatic abscess, etc.). Surgery is needed in case of infected necrosis or abscess. If the patient is not getting worse, the most suitable time for surgical intervention is 15th to 21st days.

Management of sterile pancreatic necrosis is controversial. It's possible to not manage conservatively in cases in which the lesion is limited to pancreas, not affecting the peripancreatic tissues, fullfilling less than 2/3 of the pancreas and without any organ-system dysfunction. Fine needie aspiration biopsy will give an idea whether the necrosis is infected or not. Still, some authors propose early surgical intervention for sterile necrosis because of risk of infection and organ dysfunction possible without infection.

Main purpose of surgery is the debridement of the necrotic tissues and drainage of the newly forming necrosis. Three methods are possible after necrosectomy, first is the passive drainage of the site, which is not enough for newly forming necrosis and requires reoperation in some patients. The second is long term lavage of the site and the third is laparostomy. Reoperation may still be necessary after lavage or laparostomy. Morbidity of laparostomy is high. This method is suggested in large infected necrosis affecting peripancreatic tissue.