Pancreatic necrosectomy: definitions and technique.

Pancreatic necrosis implies a permanent condition in which a portion of the pancreas loses its blood supply. This condition is irreversible, yet many cases of "necrosis" will, after recovery, culminate in a patient with a normal pancreas by computed tomography or endoscopic retrograde cholangiopancreatography. The problem is in our definitions. An understanding of this disease through its related definitions is required before judgment deems "necrosectomy to be appropriate." These definitions are of pancreatic ductal disruption, peripancreatic fluid collections, pseudocyst, pancreatic abscess, and pancreatic necrosis. The technique of necrosectomy removes mature "necrosum" and is described in this article. Once necrosectomy is completed, the surgeon still depends on the continued support of interventional radiology through regular exchange of large-bore pancreatic drains. In our institution, many of these drain sites are placed at some time before necrosectomy. Once the team method has been implemented, the following improved outcomes will result--lowered need for necrosectomy and single digit mortality.