Recent advances in the surgical management of necrotizing pancreatitis.

PURPOSE OF REVIEW: To summarize advances and new concepts in the surgical management of necrotizing pancreatitis published within the past year with emphasis on the evolving importance of the recognition of abdominal compartment syndrome as a significant contributor to early development of organ failure. RECENT
FINDINGS: Underdiagnosed and untreated, abdominal compartment syndrome is a potential contributing factor to the development of early organ failure in patients with severe acute pancreatitis and warrants routine measurement of intra-abdominal pressure in patients treated for severe pancreatitis. The current estimate of the prevalence of intra-abdominal hypertension in severe acute pancreatitis is about 40%, with about 10% overall developing abdominal compartment syndrome, associated with increased hospital mortality rates. Early surgical decompression without exploring the pancreas further seems to be the most effective treatment. Primary fascial closure of the abdominal wall following abdominal decompression can be attempted, but in most cases the prolonged inflammatory process in the abdomen and the risk of recurrent abdominal compartment syndrome favors use of gradual closure or delayed reconstruction of the abdominal wall.
SUMMARY: Recent studies confirm the overall validity of the established surgical principles for necrotizing pancreatitis: delayed necrosectomy in patients with infected peripancreatic necrosis, mostly nonoperative management of sterile necrosis, and delayed cholecystectomy in severe gallstone-associated pancreatitis. The role of abdominal compartment syndrome as an important contributing factor to early development of multiple organ failure and the potential benefit of surgical decompression are gaining support from recent reports and should be carefully assessed in future studies.