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REVIEW
Management of Severe Acute Pancreatitis
A Surgical Odyssey
Edward L. Bradley III, MD,* and Nadine D. Dexter, MLS, AHIP†
Abstract: Throughout much of history, surgery of the pancreas was restricted to
drainage of abscesses and treatment of traumatic wounds. At the turn of the 20th
century under the impetus of anesthesia, such surgical stalwarts as Mayo
Robson, Mickulicz, and Moynihan began to deploy laparotomy and gauze
drainage in an effort to salvage patients afflicted with severe acute pancreatitis
(SAP). Over the next thirty years, surgical intervention in SAP became the therapy
for choice, despite surgical mortality rates that often exceeded 50%.
When the discovery of the serum test for amylase revealed that clinically
milder forms of acute pancreatitis existed that could respond to nonoperative
therapy, a wave of conservatism emerged, and, for the next quarter century,
surgical intervention for SAP was rarely practiced. However, by the 1960s,
conservative mortality rates for SAP were reported to be as high as 60% to 80%,
leading surgeons to not only refine the indications for surgery in SAP, but also
to consider new approaches. Extensive pancreatic resections for SAP became the
vogue in continental surgical centers in the 1960s and 1970s, but often resulted
in high mortality rates and inadvertent removal of viable tissue.
Accurate diagnosis of pancreatic necrosis by dynamic CT led to new
approaches for management. Some surgeons recommended restricting inter-
vention to those with documented infected necrosis, and proposed delayed
exploration employing sequestrectomy and open-packing. Others advocated
debridement early in the course of the disease for all patients with necrotizing
pancreatitis, regardless of the status of infection. In the 1990s, however, a series
of prospective studies emerged proving that nonoperative management of
patients with sterile pancreatic necrosis was superior to surgical intervention, and
that delayed intervention provided improved surgical mortality rates.
The surgical odyssey in managing the necrotizing form of SAP, from simple
drainage, to resection, to debridement, to sequestrectomy, although somewhat
tortuous, is nevertheless an notable example of how evidence-based knowledge
leads to improvement in patient care. Today’s 10% to 20% surgical mortality
rates reflect not only considerable advances in surgical management, but also
highlight concomitant improvements in fluid therapy, antibiotics, and intensive
care. Although history documents the important contributions that surgical practi-
tioners have made to acute pancreatitis and its complications, surgeons are rarely
complacent, and the recent emergence of minimally invasive techniques holds future
promise for patients afflicted with this “. . . most formidable of catastrophes.”
(Ann Surg 2010;251: 6 –17)
fAcute pancreatitis is the most terrible of all the calamities that
occur in connection to the abdominal viscera. The suddenness of its
onset, the illimitable agony which accompanies it, and the mortality
attendant upon it, render it the most formidable of catastrophes.
—B. Moynihan, 1925
1
Surgical intervention in necrotizing pancreatitis is a relatively
recent phenomenon, encompassing only the last 6 generations of
surgeons. However, the most significant advances in diagnosis and
surgical management have occurred within the lifetime of contem-
poraries. The delay in application of operative principles to acute
necrotizing pancreatitis can be attributed to a combination of factors;
delayed recognition of necrotizing pancreatitis as a disease entity,
the remote retroperitoneal location of the gland, difficulties in
differential diagnosis, confusion in terminology, and incomplete
understanding of the metabolic needs of seriously ill patients.
Nevertheless, surgical mortality rates in necrotizing pancreatitis
have been dramatically reduced, from 60% to 80% in the early 20th
century, to the 10% to 20% rates commonly reported today. This is
the history of that progress.
THE PAST
fThe past is only the present become invisible and mute
—M. Webb, Foreword to Precious Bane
Beginning with the time of Galen (129 AD–217 AD), and
continuing well into the Middle Ages, such diverse diseases as
pancreatic malignancy, chronic pancreatitis, and various forms of
acute pancreatitis and its complications were all lumped together
under the heterogeneous classification of “scirrhi” (hard) conditions.
The longevity of ancient medical dogma was considerably abetted
by the edict from the medieval Catholic Church prohibiting human
dissection, as well as to the unwillingness of scholars to chal-
lenge the classic opinions of Galen. As a result, clinicopathologic
differentiation among human diseases did not begin to emerge
until late in the fifteenth century, when human postmortem
dissection began to be practiced in Bologna, Padua, and other
European university centers.
The first recorded description of necrotizing pancreatitis is
apparently that of Nikolaus Tulp, a Dutch physician and anatomist,
who in 1652 performed a postmortem examination upon a young
man afflicted by an apocalyptic attack of abdominal pain that proved
to be fatal after 5 days.
2
At autopsy, the gland was found to be
enlarged, purulent, and “rotten.” No explanation was offered for the
observed changes in the pancreas.
Similar anatomic studies were infrequent, however, and acute
inflammation of the pancreas continued to be considered a rare
condition. Failure to recognize acute pancreatitis as a separate
disease entity was partly because symptoms were often attributed to
other, more well-known diseases, and partly due to the relatively
small number of postmortem examinations being performed.
It was not until 1842 that acute pancreatitis was proposed as
a distinct clinical entity. Heinrich Claessen, a physician in Cologne,
collected a series of 6 fatal cases of severe acute pancreatitis from
the literature of the times.
3
He noted a common clinical and
pathologic presentation among these cases, and suggested that this
commonality in presentation might be useful for diagnosis.
Over the next 50 years, increasing numbers of autopsy-based
studies of necrotizing pancreatitis by such eminent pathologists as
From the *Department of Clinical Sciences (Surgery), Florida State University
College of Medicine, Tallahassee, FL; and †Reference Library, Charlotte
Edwards McGuire Medical Library, Florida State University College of
Medicine, Tallahassee, FL.
Nadine D. Dexter is currently at Harriet F. Ginsberg Health Sciences Library,
University of Central Florida College of Medicine, Orlando, FL.
Reprints: Edward L. Bradley, III, MD, 1600 Baywood Way, Sarasota, FL. E-mail:
ed.bradley@med.fsu.edu.
Copyright © 2009 by Lippincott Williams & Wilkins
ISSN: 0003-4932/10/25101-0006
DOI: 10.1097/SLA.0b013e3181c72b79
Annals of Surgery • Volume 251, Number 1, January 20106| www.annalsofsurgery.com
Rokitansky, Klebs, Friedrich, and Chiari, confirmed Claessen’s
initial clinical observations.
4–7
Theodor Klebs, a student of Vir-
chow, and professor of pathologic anatomy and bacteriology in
Berne, proposed that hemorrhagic pancreatitis was related to necro-
tizing pancreatitis, and to subsequent suppuration of the gland.
Moreover, he first postulated that the destruction of the pancreas was
caused by the well-known “corroding qualities” of the gland secre-
tions. Nikolaus Friedreich, also a student of Virchow, who later rose
to become professor of pathology in Wurzberg, suggested a post-
mortem classification of acute pancreatitis in 1882 consisting of
hemorrhage, gangrene, and abscess formation. His classification was
admittedly restricted as it was based upon but 4 cases, only one of
which was personally observed by the author. A year later, Hans
Chiari, professor of pathology in Prague, published his findings
concerning the pathophysiology of acute pancreatitis, attributing the
destruction of the gland to the “autodigestive” properties of pancre-
atic ferments.
In 1889, Reginald Fitz, the Shattuck Professor of Patho-
anatomy at Harvard, former pupil of Rokitansky, Virchow, and
Billroth, and already well known for his clinicopathologic descrip-
tion of appendicitis, published a Hunterian Lecture in which a
pathology-based classification system for acute pancreatitis was
proposed (Fig. 1). As a result of Fitz’ classification system, clini-
cians were enabled to make an antemortem diagnosis of acute
pancreatitis.
8
Although this autopsy-based classification system,
including hemorrhagic, gangrenous, and suppurative forms, was
superficially similar to the earlier one proposed by Friedrich, Fitz’s
classification system involved a melding of clinical symptomatology
and pathologic findings derived from a painstaking collective review
of prior cases in the literature, with a few cases added from the
Boston area. Even though Fitz noted that the hemorrhagic, suppu-
rative, and gangrenous forms of acute pancreatitis were often com-
bined with disseminated fat necrosis, he was seemingly unaware that
fat necrosis was a different manifestation of the same disease
process.
During this period of awakening interest in the pancreas,
surgeons were not idle. According to Hollender,
9
Wandeleben had
incised and drained a pancreatic abscess as early as 1845, although
the result of this effort is unknown. In 1882, Rosenbach marsupial-
ized an abscess of the pancreas. Unfortunately, the patient died,
reportedly in “schock” 6 hours after surgery.
10
Hirschberg per-
formed an exploratory laparotomy in 1887 in an obese male who had
suffered a “collapse” 4 days after the onset of hemorrhagic pancreatitis,
but within 5 hours after exploration, his patient also expired.
11
These
initially unsuccessful forays into the surgical management of necrotiz-
ing pancreatitis did not deter surgical interest.
In 1886, Nikolas Senn (Fig. 2) published extensive animal
experiments describing surgery of the gland.
12
Furthermore, he
offered his own clinical classification of acute pancreatitis, embod-
ying gangrene, abscess, and hemorrhage of the gland, 3 years prior
to the classification proposed by Fitz. Senn wrote that “One of the
terminations of acute inflammation of the pancreas is gangrene. It
would seem plausible that timely removal of the necrosed organ by
surgical interference would add to the chances of recovery. Conse-
quently, we shall add gangrene as one of the diseases of the pancreas
which should be treated by operative measures” (p 175). Of note,
FIGURE 1. Reginald Huber Fitz (1843–1913). American pa-
thologist who studied under Rudolf Virchow, and brought
the European concept of the importance of the microscopic
examination of tissues back to America. As the Shattuck Pro-
fessor of Pathoanatomy at Harvard, he established the first
clinicopathologic classification of acute appendicitis. His sub-
sequent pathology based classification of acute pancreatitis
enabled clinicians to make an antemortem diagnosis of se-
vere acute pancreatitis.
FIGURE 2. Nicholas Senn (1844–1908). A childhood immi-
grant from Switzerland, Senn graduated from Chicago Medi-
cal School in 1868. After working at Cook County Hospital
for several years, he journeyed to Munich for postgraduate
studies under Professor Johann von Nussbaum. In 1878, he
joined the faculty at Rush Medical College as Professor of
Surgery. While at Rush, he carried out numerous animal ex-
periments involving surgery of the pancreas, thereby provid-
ing the investigative basis for future generations of surgical
scientists. He left his position in 1898 to become Chief Sur-
geon of the Army Medical Corps in Cuba during the Span-
ish-American War.
Annals of Surgery • Volume 251, Number 1, January 2010 Management of Severe Acute Pancreatitis
© 2009 Lippincott Williams & Wilkins www.annalsofsurgery.com |7
however, although Senn remained a staunch advocate for surgical
intervention in acute pancreatitis for his entire career, there does not
seem to be any record of whether he actually performed such
operations. Nevertheless, his influence on the so-called “Chicago
School of Surgery” was profound and long-lasting. Senn’s applica-
tion of the scientific method to a clinical problem ignited the interest
of many other surgeons to employ surgical techniques in human
acute pancreatitis.
Many students of surgical history are aware that 3 years later
in 1889, Fitz was adamant that surgery would not benefit patients
with acute pancreatitis, and that fatalities could not be prevented by
operative “meddling.” Less well known, however, is the observation
that Fitz appeared to modify his antisurgical stance in a subsequent
publication in 1903, in which he allowed that some surgical suc-
cesses had been reported in these desperately ill patients.
13
The initial operative success in the management of necrotiz-
ing pancreatitis was reported by Werner Koerte (Fig. 3) in 1894. He
described the successful drainage of a large pancreatic abscess via a
left flank incision in a 48-year-old obese woman 1 month after the
onset of severe pancreatitis.
14
Iodoform gauze-wrapped drains were
placed into the retroperitoneum, and postoperative management
consisted of repeated changes of the gauze. After wound discharge
of a considerable amount of necrotic pancreas and fatty tissue, and
the formation of a pancreatic fistula, the patient was discharged
completely healed 5 months later. Unfortunately, 2 other cases of
postnecrotic abscess in his series that were treated similarly expired
due to recurrent infection. Koerte advocated delayed exploration of
pancreatic infections: “In the acute stage, surgical treatment is not
recommended, wherein patients have the propensity for cardiovas-
cular collapse. If pancreatic apoplexy occurs, surgical treatment
cannot help. Later, when we can prove that a purulent collection is
arising from the gland, surgery is indicated” (p 739). These thoughts
antedate the contemporary approach to surgery for necrotizing
pancreatitis by more than 90 years.
One year later, in 1895, Thayer from the Johns Hopkins
Hospital reported a similar case of necrotizing pancreatitis with
secondary infection that had been operated upon by JMT Finney,
using debridement and closed drainage. The patient recovered and
was discharged 4 months after the initial exploration.
15
Six years
later, from the same institution, Opie generalized from a single
autopsy case that hemorrhagic pancreatitis resulted from unremitting
obstruction of the pancreatic and bile ducts by biliary calculi.
16
Given these initial successes, surgeons flocked to the banner
of operative intervention in acute pancreatitis.
17–19
At the turn of the
twentieth century, such surgical stalwarts as Mayo Robson and
Mickulicz also reported successful surgical interventions in necro-
tizing pancreatitis. In the second of 3 scholarly Hunterian Lectures
given before the Royal College of Surgeons of England in 1904,
Mayo Robson (Fig. 4) described 2 survivors in 4 early operations for
necrotizing pancreatitis, and 5 survivors in 6 operations for pancre-
atic abscess.
20
He noted that in contrast to previous beliefs “…
inflammatory afflictions of the pancreas are very much more com-
FIGURE 3. Werner Koerte (1853–1937). Born in Berlin, the
son of a famous physician, he received his MD from the Uni-
versity of Strasburg. In 1889, he was appointed chief sur-
geon of the Urban Hospital in Berlin, where he achieved in-
ternational acclaim as a surgical technician and excellent
teacher. Among his many teachings was the admonition
that it was more important to know when not to perform
surgery. He became President of both the Berlin and Ger-
man Surgical Societies, and was honored by the German
government with the issue of a stamp bearing his likeness.
FIGURE 4. Arthur W. Mayo Robson (1853–1933). Born in
Filey in the United Kingdom, the son of a chemist, he
trained in medicine at Leeds, at graduation becoming lec-
turer in Anatomy at the University. In 1890, he was ap-
pointed Professor of Surgery at the Leeds Infirmary, where
he achieved recognition as a pioneer in surgery of the pan-
creas and bile ducts. He also undertook removal of knee car-
tilages before orthopedics became a specialty. Mayo Robson
was widely known for his speed and skill as a surgeon, and
later moved to London to further his career, where he was
knighted in 1908. In the First World War, he served in
France with a field ambulance, followed by distinguished
service in other war theaters. His many honors included KBE,
CB, CVO, MRCS Eng, FRCS Eng, and DSc (Hon) Leeds.
Bradley and Dexter Annals of Surgery • Volume 251, Number 1, January 2010
8| www.annalsofsurgery.com © 2009 Lippincott Williams & Wilkins
mon than is generally supposed” (p 846). Johann von Mikulicz,
Professor of Surgery in Breslau, and also a former student of
Billroth, advocated early exploration in necrotizing pancreatitis, but
favored pancreatic marsupialization by “pancreatostomy,” rather
than by gauze drainage.
21
In rapid succession, other surgeons reported successful pro-
cedures in patients with necrotizing pancreatitis and its complica-
tions. Woolsey, a Professor of Surgery at Columbia, described 3
cases of successful early exploration in necrotizing pancreatitis
employing debridement and gauze drainage.
22
Similarly successful
anecdotal experiences with this approach were reported by Bunge
23
and Villar.
24
The favored technique consisted of surgical interven-
tion early in the course of acute hemorrhagic/necrotizing pancreati-
tis, incisions into the pancreatic “capsule,” and gauze drainage of the
peripancreatic region. In contrast, delayed intervention for pancre-
atic abscesses was preferred, employing marsupialization and gauze
packing, with or without a counter-incision in the flank.
As a result of these and other successful reports, surgical
intervention in necrotizing pancreatitis became established policy
for the next quarter century, even though surgeons continued to
dispute the optimal timing for surgical intervention, as well as the
specific surgical techniques to be employed. In an undeniable
display of surgical zeal, Hoffman in 1911 attempted to perform total
pancreatectomy in a patient with hemorrhagic pancreatitis, but was
forced to withdraw because of heavy bleeding.
25
This romance with surgical intervention in clinically diagnos-
able severe acute pancreatitis continued well into the 1920s, perhaps
reaching its zenith with Moynihan’s statement in 1925 expressing
doubt that survival from necrotizing pancreatitis could ever be
expected without early surgical intervention: “… recovery from this
disease, apart from operation, is so rare that no case should be left
untreated.”
1
Lord Moynihan, Professor of Surgery at Leeds in
England, had adopted Professor Koerte’s approach of wound closure
over gauze wrapped drains, but because of the large number of
patients in his clinic with associated biliary disease, he also added
cholecystostomy to the technique.
In 1927, Professor Viktor Schmieden of the University of
Frankfurt reported a series of 1510 patients with necrotizing pan-
creatitis collected from 124 international clinics over the preceding
8-year period.
26
Of the 1278 cases who had undergone surgery, the
overall mortality was 51%. The authors registered surprise that this
mortality rate was not appreciably different from the 60% mortality
rate experienced at the turn of the century. Mortality rates were
noted to be highest in hemorrhagic (60%) and necrotizing pancre-
atitis (65%), and lowest in acute edematous pancreatitis (24%). They
advocated early surgical intervention within days of onset, longitu-
dinal incisions into the gland for “decompression,” and tampon
drainage for 6 to 8 days. “The (abdominal) incision should be kept
wide open for many weeks because of the persistent pancreatic
enzyme secretion, and also because of the extremely long time
required for the discharge of the gland sequestra” (p 751). Of
passing interest in this report is Schmieden’s proposal that the
mechanism for necrotizing pancreatitis associated with gallstones
might be due to “the passage of concretions with their temporary
fixation of the ampulla of Vater …” Schmieden’s theory of
pathophysiology of biliary pancreatitis preceded by almost 50
years the report of Acosta and his associates confirming transient
obstruction of the pancreatic duct at the ampulla as the respon-
sible mechanism.
27
Despite the prevailing opinion that only surgical intervention
in acute pancreatitis was capable of preventing death, practical
difficulties in the performance of surgical therapy and postoperative
care were widely appreciated. As Okinczyc wrote in 1933, “Go right
to the target, expose the gland, drain, and hope!”
28
Continuing difficulties in the clinical diagnosis of acute pan-
creatitis no doubt accounted for a significant portion of this initial
surgical mortality, as only the most florid and severe examples of
pancreatitis were easily diagnosed. In essence, the measure of
severity of an episode of acute pancreatitis during these times was its
very ability to be diagnosed. All that changed in 1929, when Elman
et al proposed that a serum test for amylase could reliably diagnose
acute pancreatitis.
29
At the time of this epochal paper, Elman was a
surgical resident working under Professor Evarts Graham at the
Barnes Hospital in St. Louis. In one definitive stroke, Elman et al
enabled acute pancreatitis to be differentiated from other abdom-
inal conditions without the necessity for surgical intervention.
Serum amylase became the simple diagnostic test for acute
pancreatitis for which Koerte and other clinicians had longed
several generations earlier.
As information regarding serum amylase began to accumu-
late, however, it soon became apparent that most of patients with
acute pancreatitis had a much milder form of the disease. As a result,
physicians began to question the dominant opinion that surgery in
acute pancreatitis was necessary for survival. In 1929, Peter Walzel,
a Viennese surgeon, was the first to point out that conservative
treatment of the more common form of the disease was demonstra-
bly superior to mortality rates from surgical intervention, which at
that time ranged between 50% to 78%.
30
Moreover, he stated that
acute edematous pancreatitis and necrotizing pancreatitis were 2
different diseases; thereby contradicting the widely held view that
edematous pancreatitis was a necessary precursor to necrotizing
pancreatitis.
Nonoperative management of acute pancreatitis was rapidly
championed by Mikelson, Demel, and Nordmann in Europe,
31–33
and by Trasoff, Pratt, Fallis, and Lewison in North America.
34–37
From the early 1930s until the late 1950s, surgical intervention in
acute pancreatitis was rarely practiced.
However, conservative therapy proved not to be the pancre-
atitis panacea than had been initially hoped. In 1948, Paxton and
Payne from the Los Angeles County General Hospital reported a
consecutive series of 307 patients with acute pancreatitis and an
overall mortality of 33%. Upon subanalysis, surgical mortality was
noted to be 45%, while nonoperative cases experienced a mortality
of 28%.
38
Although the comparatively lower conservative mortality
was considered by the authors to be support for the nonsurgical
approach, it also had the undesired effect of demonstrating that
conservatively treated patients continued to expire at a high rate. In
a 1959 review of 100 consecutive cases of acute pancreatitis from
the University of Leeds, Pollock re-emphasized that patients with
severe acute pancreatitis continued to expire despite the best efforts
of conservative management.
39
In this series, a number of patients
with necrotizing pancreatitis underwent transduodenal pancreatog-
raphy, with the frequent finding of a disruption of the main pancre-
atic duct. These initial observations of the necrotizing process
extending to include the pancreatic duct were confirmed 30 years
later by our group using endoscopic retrograde cholangiopancre-
atography in patients following recovery from necrotizing pancre-
atitis.
40
In a subsequent report from Naples, Uomo and his associ-
ates documented the frequency of duct disruptions in more than 30%
of patients with necrotizing pancreatitis.
41
Even today, the clinical
significance of necrosis-induced duct disruption in acute pancreatitis
is not known with certainty. A few surgeons have called for
resection of the involved section of the gland whenever duct dis-
ruption has been demonstrated,
42,43
but since the majority of pa-
tients with proved duct disruption recover without consequence,
41
a
conservative approach seems justified.
Concerns for the high mortality rate in severe acute pancre-
atitis treated conservatively were also voiced by Foster and Ziffren
Annals of Surgery • Volume 251, Number 1, January 2010 Management of Severe Acute Pancreatitis
© 2009 Lippincott Williams & Wilkins www.annalsofsurgery.com |9
in 1962. They noted mortality rates for conservative therapy to
exceed 80% in some instances.
44
Subsequently, other workers re-
ported mortality rates with persistent medical treatment of severe
acute pancreatitis in the range of 50% to 90%.
45,46
Fuel for the
selective surgical fires, indeed! Although from today’s evidence-
based perspective, these historical mortality rates for conservatively
treated severe acute pancreatitis would be considered uncontrolled
and questionable, they were considered authoritative at the time. As
a result, such articles served to establish a high-level risk for
conservative treatment of the clinically severe form of acute pan-
creatitis. Accordingly, surgeons began to wonder once again
whether a more selective indication for surgical intervention in
severe acute pancreatitis might further improve mortality.
For many years, surgeons had considered it axiomatic that the
presence of necrotic tissue was sufficient to mandate its removal.
Sporadic attempts at extirpation of the gland for necrotizing pancre-
atitis had been undertaken following the initial unsuccessful attempt
by Hoffman in 1911. In 1945, Dargent of Lyon was able to complete
an emergency total pancreatectomy for necrotizing pancreatitis, but
the patient did not survive.
47
Chau et al reported the first successful
distal resection of the pancreas for necrotizing pancreatitis in
1959.
48
Four years later, George Watts, a consultant surgeon at the
Birmingham General Hospital in England, performed the first suc-
cessful total pancreatectomy for a patient in shock with “fulminant”
acute pancreatitis.
49
While covering less than 1 page in The Lancet,
this report generated widespread interest in pancreatic resection for
patients with severe acute pancreatitis.
Using “failure to respond to supportive therapy” as the
primary indication for surgical intervention in severe acute pancre-
atitis, a number of continental surgeons rapidly developed experi-
ence with extensive ablative surgery in this high-risk group.
50–63
Surgical intervention was usually initiated within 48 hours of onset
of the acute episode, and consisted of left resections and occasional
total pancreatectomies. Mortality rates ranged from 28% for distal
resections
59
to 60% for duodenopancreatectomies.
60
However, mul-
tiple reoperations were necessary in more than three quarters of
patients with these ablative approaches, primarily for postoperative
infection and hemorrhage. The largest experience with ablative
surgery during this period was that of Professor Louis Hollender et
al of Strasburg (Fig. 5) Beginning in 1967, Hollender et al employed
capsular incisions in the gland and early resection of hemorrhagic
segments.
64
Later, these resections were combined with necrosec-
tomies and lavage. Overall, they were able to achieve a mortality
rate of 26% in 82 patients.
64–67
Hollender’s statement that, “Con-
servative treatment may delay a fatal outcome, but very seldom
prevents death.”
67
was representative of the opinions of the ablative
surgeons during this time.
The comparative success of pancreatic resection for the
necrohemorrhagic form of acute pancreatitis exhibited during the
1960s and the 1970s was in sharp contrast with the 50% to 70%
mortality rates for resection experienced during the first quarter of
the century. In many ways, however, this improvement in the
mortality of resection was due to major breakthroughs in the under-
standing of surgical metabolism and fluid requirements that had
been generated by the combined works of Francis Moore,
68
Tom
Shires,
69
and Shoemaker and Walker.
70
As a surgical house officer
in the early 1960s, the senior author can recall being advised to give
vasoconstrictors to patients in shock with severe acute pancreatitis!
At that time, pharmacologic support of the blood pressure was
considered state-of-the-art supportive therapy, despite the emer-
gence of an extensive parallel experience in renal failure. In a series
of remarkable insights into human fluid homeostasis, this trio of
surgical investigators had not only dramatically improved the post-
operative care of contemporary surgical patients, but also had
provided the framework for modern conservative management.
Even though ablative surgery was widely practiced in Euro-
pean surgical centers, extended resections never really caught on
elsewhere, the exception being the report of Norton and Eiseman
from America detailing near total pancreatectomies in 4 patients
with necrotizing pancreatitis.
71
Although overall mortality rates for
early pancreatic resection in the necrohemorrhagic form of acute
pancreatitis ranged from 30% to 50% for left resections, to 80% for
total pancreatectomies, surgeons at that time believed that these
mortality results were superior to those historical mortality rates
from supportive therapy in similarly severe cases.
During the time that pancreatic resection held sway on the
Continent, more conservative operative techniques were being prac-
ticed in the United States. In 1963, Altemeier and Alexander from
the University of Cincinnati reported the largest series up to that
time of proved pancreatic abscesses from a single institution.
72
Eighteen of the 21 patients survived that were treated with incision
and passive drainage with Penrose drains placed through flank
incisions, whereas all 11 patients treated conservatively died. De-
bridement and closed passive drainage came to be known as the
“conventional” approach to pancreatic infections.
FIGURE 5. Louis Francois Hollender (1922–Contemporary).
Born in Strasbourg, he completed his MD in Freiburg and
Paris, and surgical training under Professor Weiss at the Uni-
versity of Strasbourg. He rose to become Professor of Sur-
gery at the Louis Pasteur University in 1970, and spent sev-
eral sabbatical years in surgical departments in America and
Europe. He achieved the unofficial status of “Surgical Ambas-
sador to the World” through his many visiting professorships
on 5 continents. Professor Hollender is widely published,
with many texts and articles covering the spectrum of gen-
eral surgery. He has been honored as a Commander of the
Legion of Honor, and also with the French Cross.
Bradley and Dexter Annals of Surgery • Volume 251, Number 1, January 2010
10 | www.annalsofsurgery.com © 2009 Lippincott Williams & Wilkins
Less radical surgery for acute pancreatitis and its complica-
tions became more effective with a 1968 report from Louisville of
an improved form of sump drainage, developed during animal
experiments by Waterman et al.
73
All 10 patients undergoing early
operation in the necrohemorrhagic stage survived with the use of
sump drainage for extended postoperative periods. Cholecystos-
tomy, gastrostomy, and feeding jejunostomy (“triple ostomy”) were
added to sump drainage in 1970 by Lawson et al from the Massa-
chusetts General Hospital.
74
Of 15 patients with necrohemorrhagic
pancreatitis treated by early surgical intervention using this method,
11 survived. The 4 deaths were due to infection in the later stages of
the disease, causing the authors to state that, “Late sepsis, however,
remains a difficult clinical problem” (p 614). In a follow-up study 4
years later of 38 patients from the same institution using the triple
ostomy approach, Warshaw et al reported a mortality rate of 34%,
employing early surgical intervention within the first 48 hours of the
attack.
75
White and Heimbach were equally reluctant to employ
major pancreatic resections for necrotizing pancreatitis. In 1976,
they reported an observed mortality of 20% in 30 patients with
refractory hemorrhagic pancreatitis treated with sump drainage,
intravenous hyperalimentation, and the triple ostomy approach.
76
Half of their patients required a secondary procedure, most
commonly for postoperative infection. The late mortality prob-
lem with sepsis experienced by the MGH group was improved in
this latter series by reoperation “on demand,” and removal of
infected necrotic tissues.
As the European experience with resections of the pancreas
for acute pancreatitis increased in number, a great deal of pancreatic
tissue from patients with the clinically severe forms of the disease
became available for histologic examination. From this wealth of
anatomic information, 2 principal observations were made. First,
necrotizing pancreatitis was present in the overwhelming majority of
SAP cases, thereby suggesting that the necrotizing process was
related to the severity of clinical manifestations. But extensive
resections were frequently found to include areas of viable pancre-
atic tissue within the operative specimen, demonstrating that necro-
sis could be superficial or patchy in nature, and that estimations of
the extent of necrosis at surgery were unreliable. These observations
suggested that many of the ablative surgical procedures had been
more extensive than necessary.
77,78
Given the observed high mor-
tality rates for extensive pancreatic resections in the necrohemor-
rhagic phase of the disease, as well as the inability to detect viable
pancreatic tissue within the areas proposed for resection, many
surgeons sought alternatives to early intervention and extensive
resections in necrotizing pancreatitis.
THE PRESENT
The modern era for surgery of SAP can be said to have begun
with attempts to predict the severity of an attack of acute pancre-
atitis. It was hoped that establishing severity could identify those
patients with SAP who might benefit from surgery, or indicate those
requiring more extensive supportive therapy. The initial attempt to
predict SAP was provided by Ranson et al in 1974 who described a
combination of clinical observations and easily obtainable labora-
tory tests that were highly correlated with a severe clinical course.
79
Shortly thereafter, a number of Continental surgeons proposed that
the presence and extent of pancreatic necrosis was the principal
determinant of the severity of acute pancreatitis. Today, we know
that the presence of organ failure is more highly correlated with
severity than is the presence of necrosis.
80
Establishing these clinical and pathologic parameters of se-
verity, however, generated a series of important clinical questions:
How can the necrotizing form of acute pancreatitis be diagnosed
clinically? What are the indications for surgical intervention? What
is the optimal surgical technique, and when should it be done?
Diagnosis
The answer to the first question was provided in 1984 by
Leena Kivisaari, then a radiology resident at Helsinki University
Hospital, who observed that patients with necrotizing pancreatitis
failed to exhibit opacification of the necrotic portion of the pancreas
during intravenous contrast computed tomography.
81
For some time,
it had been known that organ opacification was a normal conse-
quence of the leak of the small contrast molecule from capillaries
into the interstitial space. Failure to opacify an organ was, therefore,
a priori evidence that the contrast material was not present in the
capillaries. In this instance, the absence of contrast material repre-
sented capillary thrombosis. This important observation was subse-
quently confirmed by experimental and clinical studies from Eu-
rope
82
and America,
83,84
establishing the presence of pancreatic
necrosis in more than 90% of cases failing to exhibit opacification.
Concerns from animal experiments that contrast-enhanced com-
puted tomography might lead to an exacerbation of severity of
pancreatitis, or to an increased incidence of renal insufficiency,
85
proved to be unfounded in humans.
86
Indications for Surgical Intervention
Sterile Necrosis
Despite the lack of objective evidence, a considerable body of
opinion had arisen which held that removal of necrotic pancreatic
tissue was mandatory. The rationale for this opinion was based on 3
apparently reasonable assumptions: (1) removal of dead pancreas
would prevent release of “toxic substances” causing the develop-
ment of organ failure, (2) secondary infection of the necrotic tissues
would not occur, and (3) surgical mortality rates would improve.
Hans Beger (Fig. 6) et al from Ulm were the principal
advocates of programmatic removal of pancreatic necrosis. These
interventions were carried out early in the course of SAP, and
necessarily involved patients with sterile pancreatic necrosis. Rather
than resection, they began to employ debridement of necrosis for
patients in the necrohemorrhagic phase of acute pancreatitis. Drain-
age was affected by prolonged postoperative lesser sac catheter
lavage.
87
In their initial report, the correlation between necrosis and
clinical severity was emphasized, as was the increased mortality risk
for the development of infected pancreatic necrosis. While the
successes of retroperitoneal and lesser sac lavage, as previously
demonstrated by Hollender et al
65
and Pederzoli and coworkers,
88
were well known, the substitution of debridement of pancreatic
necrosis in place of extensive resection represented a major step
forward. However, indications for surgery in Ulm included all
patients with necrotizing pancreatitis documented by contrast-en-
hanced computed tomography who were “not responding within 48
hours of intensive medical therapy,” regardless of the presence or
absence of infection. In keeping with the European tradition, surgical
intervention was urged early within the course of necrotizing pancre-
atitis, averaging 5.1 days from the onset of symptoms. As might be
expected from the fact that secondary infection of pancreatic necrosis is
primarily a delayed phenomenon most often developing several weeks
after onset, adherence to this indication for surgery resulted in a
predominance of patients with sterile pancreatic necrosis undergoing
debridement. In a 1988 report,
89
the Ulm group demonstrated an
overall mortality rate of 8.1% using these techniques in patients with
sterile pancreatic necrosis. In addition, the presence of active trypsin
and phospholipase A were noted in the effluent from the lavage
drains for as long as 12 to 14 days after operative intervention. This
finding was interpreted to mean that the necrotizing process was a
continuing one in the postoperative period, thereby providing the
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© 2009 Lippincott Williams & Wilkins www.annalsofsurgery.com |11
basis for prolonged postoperative drainage. By 1995, the group had
modified their original approach from programmatic debridement
for all patients with documented pancreatic necrosis, to one
agreeing with medical management of some patients with sterile
pancreatic necrosis, providing they improved with initial conser-
vative therapy.
90
In a 2005 summary of their collective experi-
ence, the mortality rate for the 107 operated patients consisting of
both sterile and infected necrosis was 13.1%, while the conser-
vatively treated patients exhibited a mortality rate of 6.2%.
91
Moreover, they were able to reduce the operative mortality rate
for infected necrosis to 21%. However, to achieve these com-
mendable results with the technique of debridement and lesser
sac lavage, the necessity for reoperations was required in more
than one-quarter of their cases. Postoperative hemorrhage and
recurrent sepsis were the principal indications for re-exploration.
During this same period, debridement of sterile pancreatic
necrosis was also advocated by Warshaw and his colleagues from
Boston. They described an overall mortality rate of 25% in a mixed
population of patients with both sterile and infected necrosis, using
the conventional surgical approach of debridement combined with
drainage of the lesser sac with a Penrose and sump drains.
92
Their
reoperation rate approached 20%, but the necessity for reoperation
for recurrent or persistent infection in this series was subsequently
reduced by the extensive use of guided transcutaneous drainage. In
contrast to Beger’s studies, they did not find a significant difference
in postoperative mortality rates between patients operated upon for
sterile necrotizing pancreatitis and those with infected pancreatic
necrosis. However, the patients in the MGH study were not directly
comparable to those from Ulm, as the duration from onset to surgical
intervention was 3 to 4 weeks in Boston as a result of local referral
patterns, as opposed to 5 days in the German series. Not commented
upon by the Boston authors, but calculable from the data presented,
was the observation that almost 40% of the patients operated upon
with initially sterile pancreatic necrosis became secondarily infected
in the postoperative period. Those unfortunate patients with surgi-
cally induced infections experienced a significantly higher mortality
rate (50%), than did patients remaining persistently sterile (3%). In
a 1998 report from this group composed of 64 patients divided
between sterile and infected pancreatic necrosis, they again found
that the overall mortality rate of 6% was not significantly different
between sterile and infected pancreatic necrosis.
93
As we have noted, the rationale for surgical intervention in
necrotizing pancreatitis had always been based upon suppositions
that mortality rates would be improved by surgery, and that com-
plications of necrotizing pancreatitis, such as secondary infections
and organ failure, could be eliminated or reduced. However, no
credible data had ever appeared demonstrating a procedure-related
reduction in organ failure, or reductions in any other complication of
sterile pancreatic necrosis.
94
Although surgically-induced reductions
in mortality and morbidity were widely claimed, none of the
reported surgical experiences for sterile pancreatic necrosis had
ever included the necessary control group, unoperated patients
with sterile necrosis, against whom the surgical mortality could
be compared.
In 1986, we entered patients into a prospective, longitudinal
study designed to provide the missing control group, by addressing
the fate of patients with severe acute pancreatitis and sterile pancre-
atic necrosis who were not subjected to surgery. From a total group
of 194 cases admitted for severe acute pancreatitis over a 3 year
period, 11 patients with were identified with pancreatic necrosis
involving 30% to 60% of the gland by CECT, most with accompa-
nying organ failure. Fine needle aspiration cultures were persistently
negative in each of these 11 patients. Moreover, each patient was
successfully managed with persistent medical therapy.
95
From these
observations, we concluded that neither the presence of sterile
pancreatic necrosis, nor organ failure, per se, was an indication for
surgical intervention in these patients. As these observations chal-
lenged widely held surgical dogma, considerable discussion was
engendered. Other supportive prospective studies followed rapidly,
however, demonstrating mortality rates for nonoperative manage-
ment of patients with sterile necrotizing pancreatitis that were equal
or superior to surgical mortality rates.
96–101
These studies have
provided the rationale for acceptance of the conservative approach
to the management of patients with sterile pancreatic necrosis in
practice today.
Even though the shift away from surgical intervention and
toward conservative management of sterile pancreatic necrosis has
resulted in a lower mortality rate for most of these patients, a small
number of patients with sterile necrosis remain who can benefit from
operative intervention. Postnecrotic disruption of the main pancre-
atic duct, variably referred to as “persistent pancreatitis,”
102
“refeed-
ing pancreatitis,”
40
or “disconnected duct syndrome,”
103
can result
in recurrent abdominal pain and hyperamylasemia following at-
tempts at reinstitution of oral alimentation after clinical recovery
FIGURE 6. Hans Gunter Beger (1936–Contemporary). Born
in Dresden, he attended medical school in Bonn, and surgi-
cal training under Professor Emil Buecherl at the Charlotten-
berg Clinic of the Free University of Berlin. He worked in the
surgical clinics of Dr. McDermott, Dr. Eiseman, and Dr.
Starzl in America, and rose to the rank of Professor in Berlin
in 1978. Called to the chairmanship at the University of Ulm
in 1982, he proceeded to establish a world-famous center
for pancreatic surgery. Following the traditions of Billroth
and Buecherl, translational research was brought to the bed-
side, and a new school of academic surgeons was founded.
His honors include Fellowship in the American College of
Surgeons, Presidencies of the European Pancreatic Club and
the International Association of Pancreatology, and multiple
scientific awards from 4 continents.
Bradley and Dexter Annals of Surgery • Volume 251, Number 1, January 2010
12 | www.annalsofsurgery.com © 2009 Lippincott Williams & Wilkins
from necrotizing pancreatitis. Longer standing postnecrotic stric-
tures may result in “upstream” chronic pancreatitis,
103
enteric
obstruction due to ischemia,
104
or common duct obstruction,
105
each of which responds favorably to surgical therapy. These
complications of necrotizing pancreatitis are relatively uncom-
mon, occurring in perhaps 2% to 3% of cases,
105
but may become
more evident as the experience with conservative management of
sterile necrosis increases.
Infected Necrosis
In contrast to the controversies concerned with whether or not
surgical intervention was necessary in patients with sterile necrotiz-
ing pancreatitis, until very recently, there was almost universal
agreement that surgical intervention was mandatory in patients with
infected pancreatic necrosis. Whatever discussions existed revolved
around other issues, such as the preferred surgical technique for
infected pancreatic necrosis and the timing of surgical intervention.
Differentiation of a systemic inflammatory response from
secondary infection of pancreatic necrosis was markedly facilitated
by the studies of Gerzof et al from the Brigham Hospital when they
demonstrated the diagnostic precision and safety of CT-guided fine
needle aspiration of the pancreatic area, with gram staining and
culture of the aspirate.
106
Even into the 1980s, however, operative mortality rates for
patients with infected pancreatic necrosis using the conventional
approach of debridement and closed Penrose drainage had often
remained in the 30% to 60% range.
107
Many of the deaths were
caused by delays in postoperative re-exploration for recurrent infec-
tion, or by retroperitoneal hemorrhage, both accounting for neces-
sary reoperation in 1 patient in 3 undergoing conventional drainage.
In an effort to address these problems and improve these
mortality statistics, in 1976 we embarked upon a different surgical
direction. Employing a technique that consisted of delayed seques-
trectomy and planned serial re-explorations, marked improvements
in historical mortality rates were observed.
108
Healing of the ab-
dominal cavity was initially permitted to occur by secondary inten-
tion. At the time of our initial report in 1981, we were unaware of
Koerte’s recommendation almost 100 years earlier for prolonged drain-
age by keeping the abdominal wound open. However, we were aware
of the efforts of Bolooki et al in treating 20 patients with suture-created
marsupialization, with a resultant mortality of 50%.
109
Improvements to our original technique were added over the
course of years, including; placement of a nonadherent gauze over
the exposed stomach and colon to prevent inadvertent debridement
of the intestinal tract and subsequent intestinal fistulization, routine
placement of a feeding jejunostomy as first recommended by Kiek-
ens et al,
110
keeping the packs continually moist with a bioticide,
and secondary closure of the abdominal wall.
111
Secondary closure
was accompanied by the placement of 2 large sump drains in the
retroperitoneal area for continuous lavage. At the time of our last
report, our mortality experience with what came to be known as
“open packing,” was 14% in 102 patients with documented infected
pancreatic necrosis.
112
Today, however, the senior author would
recommend reserving the open drainage technique for patients with
large collections extending bilaterally across the retroperitoneum
and into the retrocolic spaces, and in those situations in which
bleeding from contiguous vessels is difficult to control with standard
measures.
Frey et al from the University of California in Sacramento
were early proponents of the open packing technique for infected
pancreatic necrosis, reporting a series of 83 patients, with an overall
mortality of 17%.
113
In the Mayo Clinic experience with infected
necrosis summarized by Sarr et al, the mortality rate was also found
to be 17%, with a minimal incidence of recurrent infection.
114
In a
series of patients undergoing open packing for infected pancreatic
necrosis collected from world surgical centers in 1998, the combined
overall mortality rate was also noted to be 17%.
112
Howard has
pointed out the important essential differences between infected
pancreatic necrosis and infected peripancreatic fat necrosis, with the
latter experiencing a significantly lower mortality rate of 3%.
115,116
Other surgeons continued to advocate conventional tech-
niques in patients with infected pancreatic necrosis, using either
closed surgical drainage, or lesser sac lavage. Fernandez and his
group from the MGH reported a mortality rate of 8% in 36 selected
patients with infected necrosis using Penrose drainage, in combina-
tion with guided percutaneous drainage of recurrent abscesses and a
low threshold for surgical re-exploration.
93
The collected experience
of Beger and his associates in Germany with debridement and lesser
sac lavage for infected necrosis had produced a mortality rate of
21%, which included a reoperation rate of 40%.
91
However, com-
parisons between the 3 alternative surgical approaches to infected
necrosis were made difficult by numerous variations between the
patient populations, the inclusion of lesser risk patients with sterile
necrosis in some series, differences in timing of surgical interven-
tion, and variations in operative technique. In the absence of evi-
dence-based studies comparing the 3 techniques, superiority could
not be assigned to any one approach. Since the results from each
surgical approach in expert hands seemed to represent a consider-
able improvement over previous mortality rates using the traditional
approach, choosing the technique with which one felt most com-
fortable seemed to be the most reasonable conclusion.
Nonsurgical Management of Infected Necrosis
Anecdotal reports of patients with documented infected pan-
creatic necrosis surviving without surgical intervention have re-
cently appeared.
117,118
The majority of these reports have been
composed of patients who had either refused surgery, or were
considered to be excessive surgical risks. Prolonged antibiotic ad-
ministration, assisted in some cases by guided percutaneous drain-
age and markedly delayed surgical “rescue,” led to successful
conclusions. These reports have called into question the surgical
dictum of mandatory surgical drainage for all patients with infected
pancreatic necrosis. However, the number of patients who might be
successfully managed by this nonoperative approach is not known.
Given the excessive mortality with nonsurgical therapy for infected
pancreatic necrosis demonstrated in the past, randomization between
operative debridement and persistent antibiotics is unlikely to ever
be done. Furthermore, since fatalities with the nonoperative ap-
proach to infected necrosis are probably underreported, nonopera-
tive management may best be reserved for patients refusing surgery,
or for those exhibiting severe comorbidities.
Timing of Surgical Intervention
Throughout the 1980s and 1990s, the timing of surgical
intervention in acute necrotizing pancreatitis re-emerged as an issue,
between those favoring “early” intervention (within the first week of
illness),
50– 67,89
and those advocating “delayed” procedures (2– 4
weeks after onset).
111,113–115
In one sense, this controversy was an
artificial one, since those favoring early intervention were primarily
surgeons advocating debridement of sterile pancreatic necrosis in
the early necrohemorrhagic phase, while proponents of the delayed
approach were surgeons restricting intervention to patients until the
later appearance of infected necrosis. With the indications for
surgery in necrotizing pancreatitis shifting away from intervention
in patients with sterile pancreatic necrosis, the advantages of delayed
intervention soon became apparent. Those advantages included
clearer demarcation between necrotic and viable tissues over time,
technical ease of debridement at a later time, clearer CT depictions
of the extent of the infectious process, and better control of the
metabolic and organ consequences of necrotizing pancreatitis. The
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© 2009 Lippincott Williams & Wilkins www.annalsofsurgery.com |13
issue of the timing of surgical intervention was finally resolved with
the appearance of a randomized, controlled study by Mier et al in
1997, demonstrating a mortality advantage to the delayed ap-
proach.
119
It was necessary for them to stop the trial prior to its
scheduled conclusion due to excessive mortality in the early inter-
vention patients.
Terminology
By the 1980s, the terminology for acute pancreatitis and its
complications was in severe disarray. The authors of many articles
dealing with acute pancreatitis and its complications had seemingly
adopted the mandate of Humpty Dumpty from Alice in Wonderland,
“When I use a word it means just what I choose it to mean – neither
more nor less.”
120
The term “pancreatic abscess” was a case in
point. In a review of more than 1100 patients labeled as “pancreatic
abscess” collected from 45 articles published between 1966 and
1987, only 11 authors had actually provided a definition of “pan-
creatic abscess,” and no 2 of the definitions were the same!
107
Similarly, the term “pancreatic phlegmon” came to be used to
describe tissue that, depending on the author, could be either sterile
or infected, or composed of either edematous or necrotic tissues. A
pancreatic Tower of Babel had developed, and communications
between workers in acute pancreatitis and progress in the manage-
ment of its complications were being held hostage by imprecise
terminology. The need for standardization was apparent.
In 1992, a group of 40 internationally renowned workers in
acute pancreatitis was assembled in Atlanta for the expressed pur-
poses of devising a clinical classification system for acute pancre-
atitis and its complications, and suggesting treatment algorithms.
The symposium attendants came from 15 countries and represented
6 medical disciplines. At the completion of the meeting that came to
be known as the Atlanta Symposium, the participants had unani-
mously agreed upon a series of clinical definitions which are in use
today, 17 years after their proposal.
121
However, increasing knowl-
edge and experience over the intervening years have made some
aspects of the symposium less useful, and a contemporary update
can be anticipated.
In Table 1 are listed a number of significant historical con-
tributions that have led to the formulation of our current approach to
the management of necrotizing pancreatitis. The reader will note that
the majority of these formative events are the result of translational
clinical research conducted by surgeons.
PROLOGUE
fIt is difficult to predict, especially the future!
—Y. Berra, Former Manager, New York Yankees
Although admittedly imprecise, predictions for the future of
surgical intervention in necrotizing pancreatitis may be becoming
less difficult. Rapid advances in the technology and application of
minimally invasive surgery have provided significant patient advan-
tages over traditional operative methods, albeit not without attendant
problems and increased costs.
Even though image-guided catheterization procedures have
proved to be a valuable adjunct to therapy for some pancreatic
infections,
122,123
guided transcutaneous drainage has left much to be
desired when used as primary therapy for drainage of infected
pancreatic necrosis. Incomplete resolution of infected collections
has been common, being attributed to the inability of small-size
drainage catheters to adequately remove thick, infected, necrotic
material.
124
In 1999, Baron, a gastroenterologist from the University
of Alabama, and his associates reported removing pancreatic necro-
sis with an endoscope via a transgastric access to the collection.
125
Endoscopic drainage and removal of infected pancreatic necrosis
have now been reported by several groups. Carter et al from
Glasgow have used video-assisted sinus tract endoscopy to access
and remove the necrotic material.
126
Other techniques for endo-
scopic necrosectomy include direct retroperitoneal access,
127
and
transperitoneal laparoscopic necrosectomy.
128
Collected success
rates in approximately 200 patients undergoing endoscopic necro-
sectomy have approached 60% to 70% with low mortality, even
though multiple “sessions” are required, and surgical “rescue” is
currently necessary in about one-third of cases.
129
Currently, endo-
scopic necrosectomy techniques cannot be considered to satisfy
evidence-based criteria for complete acceptance. However, the
future for minimally invasive techniques in the management of
patients with infected pancreatic necrosis appears promising,
TABLE 1. Milestones in the Surgical History of Necrotizing
Pancreatitis
Senior Author Year Contribution
Tulp
2
1652 Initial post-mortem description of
necrotizing pancreatitis.
Klebs
5
1870 Relationship between hemorrhagic,
necrotizing, and suppurative
pancreatitis.
Chiari
7
1883 Proposed “autodigestion” as the
mechanism for pancreatic necrosis.
Senn
12
1886 Applied scientific method of animal
experimentation to surgery of the
gland.
Fitz
13
1889 Established clinicopathologic correlation
for necrotizing pancreatitis.
Koerte
14
1894 First successful operation for infected
pancreatic necrosis.
MayoRobson
20
1904 Advocated early exploration and
drainage in necro-hemorrhagic stage.
Elman et al
29
1929 Established serum amylase in diagnosis
of acute pancreatitis.
Nordmann
33
1938 Recommended conservative therapy for
all forms of acute pancreatitis.
Watts
49
1963 First successful total pancreatectomy for
“fulminant” acute pancreatitis.
Altemeier and
Alexander
72
1963 Advocated debridement and closed
drainage for pancreatic “abscess.”
Lawson et al
74
1970 Introduced “triple ostomy” and drainage
for necro-hemorrhagic phase.
Hollender
67
1979 Largest experience with early resection
in the necro-hemorrhagic phase.
Bradley and
Davidson
108
1983 Delayed sequestrectomy and planned
re-explorations for infected necrosis.
Kivisaari et al
81
1984 Diagnosis and extent of necrotizing
pancreatitis by contrast-enhanced CT.
Beger et al
89
1985 Debridement and lesser sac lavage for
all forms of necrotizing pancreatitis.
Gerzof et al
106
1987 Diagnosis of infected pancreatic necrosis
by guided fine needle aspiration.
Bradley and Allen
95
1991 Non-operative management for most
forms of sterile necrotizing
pancreatitis.
Atlanta
Symposium
121
1993 Clinically based definitions for
necrotizing pancreatitis, and proposed
treatment algorithms.
Carter et al
126
2000 Minimal access debridement and
drainage of infected pancreatic
necrosis.
Bradley and Dexter Annals of Surgery • Volume 251, Number 1, January 2010
14 | www.annalsofsurgery.com © 2009 Lippincott Williams & Wilkins
particularly as experience increases, and the inevitable technical
modifications occur.
RECOMMENDED READING
For those individuals seeking extensive historical information
on a broad range of pancreatic diseases, the scholarly work, History
of the Pancreas: Mysteries of a Hidden Organ, by John Howard and
Walter Hess, Kluwer, New York, 2002 is highly recommended.
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