title: Therapeutic intervention and surgery of acute pancreatitis.
abstract: The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. Edematous pancreatitis accounts for 80-90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10-20% of acute pancreatitis and the mortality rate is reported to be 14-25%. The mortality rate is particularly high (34-40%) for infected pancreatic necrosis that is accompanied by bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148-154, 1993; Ogawa et al. in Research of the actual situations of acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry of Health, Labour, and Welfare. Heisei 12 Research Report, pp 17-33, 2001). On the other hand, the mortality rate is reported to be 0-11% for sterile pancreatic necrosis which is not accompanied by bacterial infection (Ogawa et al. 2001; Bradely and Allen in Am J Surg 161:19-24, 1991; Rattner et al. in Am J Surg 163:105-109, 1992). The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a variety of clinical characteristics. This article describes the guidelines for the surgical management and interventional therapy of acute pancreatitis by incorporating the latest evidence for the management of acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected pancreatic necrosis; (3) conservative treatment should be performed in sterile pancreatic necrosis; (4) infected pancreatic necrosis is an indication for interventional therapy. However, conservative treatment by antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a surgical procedure for infected necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess; (9) if the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts and (11) percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases.
authors.affiliation: Department of Surgery, Teikyo University School of Medicine, 2-11-1, Kaga-cho, Itabashi, Tokyo, 173-8605, Japan. amano@med.teikyo-u.ac.jp
authors.forename: Hodaka
authors.initials: H
authors.lastname: Amano
authors.forename: Tadahiro
authors.initials: T
authors.lastname: Takada
authors.forename: Shuji
authors.initials: S
authors.lastname: Isaji
authors.forename: Yoshifumi
authors.initials: Y
authors.lastname: Takeyama
authors.forename: Koichi
authors.initials: K
authors.lastname: Hirata
authors.forename: Masahiro
authors.initials: M
authors.lastname: Yoshida
authors.forename: Toshihiko
authors.initials: T
authors.lastname: Mayumi
authors.forename: Eigoro
authors.initials: E
authors.lastname: Yamanouchi
authors.forename: Toshifumi
authors.initials: T
authors.lastname: Gabata
authors.forename: Masumi
authors.initials: M
authors.lastname: Kadoya
authors.forename: Takayuki
authors.initials: T
authors.lastname: Hattori
authors.forename: Masahiko
authors.initials: M
authors.lastname: Hirota
authors.forename: Yasutoshi
authors.initials: Y
authors.lastname: Kimura
authors.forename: Kazunori
authors.initials: K
authors.lastname: Takeda
authors.forename: Keita
authors.initials: K
authors.lastname: Wada
authors.forename: Miho
authors.initials: M
authors.lastname: Sekimoto
authors.forename: Seiki
authors.initials: S
authors.lastname: Kiriyama
authors.forename: Masamichi
authors.initials: M
authors.lastname: Yokoe
authors.forename: Morihisa
authors.initials: M
authors.lastname: Hirota
authors.forename: Shinju
authors.initials: S
authors.lastname: Arata
mesh_terms: D000038:Abscess / Q000628:therapy; D000208:Acute Disease; D044963:Biopsy, Fine-Needle; D004322:Drainage; D019317:Evidence-Based Medicine; D006801:Humans; D010179:Pancreas / Q000382:microbiology / Q000473:pathology; D010195:Pancreatitis / Q000601:surgery / Q000628:therapy*; D019283:Pancreatitis, Acute Necrotizing / Q000601:surgery / Q000628:therapy; D017410:Practice Guidelines as Topic; D015641:Radiography, Interventional