Management of Severe Acute Pancreatitis: A Surgical Odyssey

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


Annals of Surgery. 2010;251(1):6-17. 

In This Article


It is difficult to predict, especially the future!

—Y. Berra, Former Manager, New York Yankees

Although admittedly imprecise, predictions for the future of surgical intervention in necrotizing pancreatitis may be becoming less difficult. Rapid advances in the technology and application of minimally invasive surgery have provided significant patient advantages over traditional operative methods, albeit not without attendant problems and increased costs.

Even though image-guided catheterization procedures have proved to be a valuable adjunct to therapy for some pancreatic infections,[122,123] guided transcutaneous drainage has left much to be desired when used as primary therapy for drainage of infected pancreatic necrosis. Incomplete resolution of infected collections has been common, being attributed to the inability of small-size drainage catheters to adequately remove thick, infected, necrotic material.[124] In 1999, Baron, a gastroenterologist from the University of Alabama, and his associates reported removing pancreatic necrosis with an endoscope via a transgastric access to the collection.[125] Endoscopic drainage and removal of infected pancreatic necrosis have now been reported by several groups. Carter et al from Glasgow have used video-assisted sinus tract endoscopy to access and remove the necrotic material.[126] Other techniques for endoscopic necrosectomy include direct retroperitoneal access,[127] and transperitoneal laparoscopic necrosectomy.[128] Collected success rates in approximately 200 patients undergoing endoscopic necrosectomy have approached 60% to 70% with low mortality, even though multiple "sessions" are required, and surgical "rescue" is currently necessary in about one-third of cases.[129] Currently, endoscopic necrosectomy techniques cannot be considered to satisfy evidence-based criteria for complete acceptance. However, the future for minimally invasive techniques in the management of patients with infected pancreatic necrosis appears promising, particularly as experience increases, and the inevitable technical modifications occur.


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