Indications for surgery in necrotizing pancreatitis.

The decision to operate on a patient with severe acute pancreatitis is often difficult and requires mature clinical judgment. Indications that are widely accepted include to establish the differential diagnosis, when the surgeon is concerned that the symptoms are due to a disease other than pancreatitis for which an operation is mandatory; in persistent and severe biliary pancreatitis, when an obstructing gallstone is lodged in the ampulla of Vater and cannot be managed endoscopically; in the presence of infected pancreatic necrosis; and to drain a pancreatic abscess, if percutaneous drainage does not produce the desired result. Other indications that are less well defined and somewhat controversial are the presence of sterile pancreatic necrosis involving 50% or more of the pancreas, when the pancreatitis persists despite maximal medical therapy, and when a patient's condition deteriorates. For these last three indications, guidelines have been presented that permit a logical approach to management, although uncertainty remains. Surgeons should strive to describe in detail and precisely the clinical state of their patients at the time that an operation is done, as well as the findings and technical details of the operation. This should allow further refinement in the management of this vexing problem.