Management of Severe Acute Pancreatitis: A Surgical Odyssey

Edward L. Bradley III, MD; Nadine D. Dexter, MLS, AHIP

Disclosures

Annals of Surgery. 2010;251(1):6-17. 

In This Article

Abstract and Introduction

Abstract

Throughout much of history, surgery of the pancreas was restricted to drainage of abscesses and treatment of traumatic wounds. At the turn of the 20th century under the impetus of anesthesia, such surgical stalwarts as Mayo Robson, Mickulicz, and Moynihan began to deploy laparotomy and gauze drainage in an effort to salvage patients afflicted with severe acute pancreatitis (SAP). Over the next thirty years, surgical intervention in SAP became the therapy for choice, despite surgical mortality rates that often exceeded 50%.
When the discovery of the serum test for amylase revealed that clinically milder forms of acute pancreatitis existed that could respond to nonoperative therapy, a wave of conservatism emerged, and, for the next quarter century, surgical intervention for SAP was rarely practiced. However, by the 1960s, conservative mortality rates for SAP were reported to be as high as 60% to 80%, leading surgeons to not only refine the indications for surgery in SAP, but also to consider new approaches. Extensive pancreatic resections for SAP became the vogue in continental surgical centers in the 1960s and 1970s, but often resulted in high mortality rates and inadvertent removal of viable tissue.
Accurate diagnosis of pancreatic necrosis by dynamic CT led to new approaches for management. Some surgeons recommended restricting intervention to those with documented infected necrosis, and proposed delayed exploration employing sequestrectomy and open-packing. Others advocated debridement early in the course of the disease for all patients with necrotizing pancreatitis, regardless of the status of infection. In the 1990s, however, a series of prospective studies emerged proving that nonoperative management of patients with sterile pancreatic necrosis was superior to surgical intervention, and that delayed intervention provided improved surgical mortality rates.
The surgical odyssey in managing the necrotizing form of SAP, from simple drainage, to resection, to debridement, to sequestrectomy, although somewhat tortuous, is nevertheless an notable example of how evidence-based knowledge leads to improvement in patient care. Today's 10% to 20% surgical mortality rates reflect not only considerable advances in surgical management, but also highlight concomitant improvements in fluid therapy, antibiotics, and intensive care. Although history documents the important contributions that surgical practitioners have made to acute pancreatitis and its complications, surgeons are rarely complacent, and the recent emergence of minimally invasive techniques holds future promise for patients afflicted with this "... most formidable of catastrophes."

Introduction

Acute pancreatitis is the most terrible of all the calamities that occur in connection to the abdominal viscera. The suddenness of its onset, the illimitable agony which accompanies it, and the mortality attendant upon it, render it the most formidable of catastrophes.

—B. Moynihan, 1925[1]

Surgical intervention in necrotizing pancreatitis is a relatively recent phenomenon, encompassing only the last 6 generations of surgeons. However, the most significant advances in diagnosis and surgical management have occurred within the lifetime of contemporaries. The delay in application of operative principles to acute necrotizing pancreatitis can be attributed to a combination of factors; delayed recognition of necrotizing pancreatitis as a disease entity, the remote retroperitoneal location of the gland, difficulties in differential diagnosis, confusion in terminology, and incomplete understanding of the metabolic needs of seriously ill patients. Nevertheless, surgical mortality rates in necrotizing pancreatitis have been dramatically reduced, from 60% to 80% in the early 20th century, to the 10% to 20% rates commonly reported today. This is the history of that progress.

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