The current status of recognition and treatment of severe necrotizing pancreatitis.

The diagnosis and treatment of severe necrotizing pancreatitis poses a major controversy in the realm of surgery of the upper gastrointestinal tract. Certainly all investigators are in agreement that the patient with severe necrotizing pancreatitis who responds promptly and effectively to intensive resuscitative efforts and general support measures should not be operated upon. The role of therapeutic percutaneous peritoneal lavage is not well delineated, but probably does not represent any risk to the patient, and should be attempted in patients in whom the response to nonsurgical measures is questionable or transient or in whom sepsis has not supervened. Operation must be undertaken in patients who do not respond to intensive resuscitative efforts, with or without peritoneal lavage, in the first 24 to 36 hours of management, or in whom the initial response is followed by deterioration of vital organ function, specifically pulmonary, renal, and hepatic function. The presence of gallstones associated with pancreatitis that does not respond to therapy promptly also makes early operation mandatory. Although the results in the alcoholic patient are not satisfactory, the results of early operation in nonalcoholic patients with severe necrotizing pancreatitis has been most gratifying, and has yielded far superior survival rates than the nonsurgical approach.