Indications for surgery in severe acute pancreatitis.

The decision to operate on a patient with severe acute pancreatitis is often difficult and requires mature clinical judgment. Those indications that are widely accepted include: 1. For differential diagnosis, when the surgeon is concerned that the symptoms are the result of a disease other than pancreatitis for which operation is mandatory; 2. In persistent and severe biliary pancreatitis, when an obstructing gallstone that cannot be managed endoscopically is lodged at the ampulla of Vater; 3. In the presence of infected pancreatic necrosis; and 4. 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: 1. The presence of sterile pancreatic necrosis involving 50% or more of the pancreas; 2. When the pancreatitis persists in spite of maximal medical therapy; and 3. When the patient's condition deteriorates, often with the failure of one or more organ systems. For these latter three indications, guidelines have been presented that permit a logical approach to management, although uncertainty remains. Surgeons should strive to describe in precise terms the clinical state of their patients at the time that operation is performed, as well as the findings at and technical details of the surgery. This should allow further refinement in the management of this still vexing problem.