Surgical strategies in the treatment of pancreatic necrosis and infection.

Controversy still surrounds the management of necrotic and septic complications of acute pancreatitis. A review of the literature of the past decade dealing with the surgical treatment of pancreatic necrosis, pancreatic abscess and infected pancreatic necrosis has been undertaken. Three main patterns of management could be identified: (1) 'conventional treatment', consisting of pancreatic resection or necrosectomy with drainage; (2) 'local lavage', consisting of necrosectomy followed by regional lavage; and (3) 'open management', with resection or necrosectomy followed by planned multiple re-explorations. From this review it appears that local lavage and open management offer better survival prospects than conventional treatment. Open abdomen techniques, however, are associated with an increased risk of complications, such as colonic necrosis, intestinal fistula, and intra-abdominal bleeding. Excellent results can be achieved in specialized centres with any of the three methods, provided adequate debridement and prompt reoperations are undertaken if the septic state persists.