title: Treatment of necrotizing pancreatitis: redefining the role of surgery.
abstract: BACKGROUND
  Early surgical intervention in necrotizing pancreatitis (NP) is associated with high mortality. Guidelines recommend fine needle aspiration (FNA) in patients with NP and signs of sepsis. Because infection of necrosis is considered an indication for surgery, operations are often performed early. We changed treatment toward a conservative approach with FNA in selected cases only, thereby reducing the rate of necrosectomy.
  
  
  METHODS
  Retrospectively analyzed patients, all operated on for FNA-proven infection of pancreatic necrosis (n = 20, group 1) were compared to patients subjected to conservative treatment (n = 24, group 2) who were followed prospectively.
  
  
  RESULTS
  Prognostic scores did not differ between the two groups, indicating comparable severity: the Acute Physiology and Chronic Health Evaluation (APACHE II) score was 19.8 ± 1.7 versus 16 ± 2.2; the Sequential Organ Failure Assessment (SOFA) score was 8.7 ± 1.4 versus 6.9 ± 1.0, the C-reactive protein (CRP) level on day 3 was 243 ± 21 versus 291 ± 21, and the CTSI (CT severity index) was 7.8 ± 0.5 versus 7.9 ± 0.4 (p = ns). Ten patients in group 2 underwent operation because of severe extrapancreatic complications. Mortality differed significantly (45% in group 1 vs. 8.3% in group 2; p = 0.01).
  
  
  CONCLUSIONS
  A highly conservative approach avoiding open necrosectomy in NP results in significantly lower mortality than previous serial FNA and consecutive indication for surgery in case of proven infection. Open surgery in NP should be reserved for concomitant intra-abdominal complications.
authors.affiliation: Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany. guido.alsfasser@med.uni-rostock.de.
authors.forename: Guido
authors.initials: G
authors.lastname: Alsfasser
authors.affiliation: Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: Schwandner
authors.affiliation: Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany.
authors.forename: Annette
authors.initials: A
authors.lastname: Pertschy
authors.affiliation: Department of Radiology, University of Rostock, Schillingallee 35, 18057, Rostock, Germany.
authors.forename: Karlheinz
authors.initials: K
authors.lastname: Hauenstein
authors.affiliation: Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Foitzik
authors.affiliation: Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany.
authors.forename: Ernst
authors.initials: E
authors.lastname: Klar
mesh_terms: D000465:Algorithms; D044963:Biopsy, Fine-Needle; D003661:Decision Support Techniques; D004322:Drainage; D005260:Female; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000473:pathology / Q000601:surgery; D019283:Pancreatitis, Acute Necrotizing / Q000401:mortality / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D012189:Retrospective Studies; D016896:Treatment Outcome