Surgery for acute and chronic pancreatitis.

The role of surgery in acute and chronic pancreatitis will be reviewed and compared with the role of therapeutic ERCP-related procedures. First, the role of surgery in acute biliary pancreatitis and in severe necrotizing pancreatitis will be discussed. Finally, the surgical treatment of pancreatic pseudocysts and pain in chronic pancreatitis will be reviewed. BILIARY PANCREATITIS In biliary pancreatitis, the pancreatic inflammatory process is precipitated by distal obstruction of the common bile and pancreatic ducts by a gallstone. In the majority of cases, that obstruction is only temporary, and probably quite brief, as the gallstone either passes through the papilla of Vater into the duodenum or becomes dislodged spontaneously and passes back into the common bile duct. When either of these occurs, there is no urgent need for either surgical or endoscopic intervention. The pancreatitis usually begins to resolve soon after the obstruction is relieved. Occasionally, however, the stone becomes impacted, the obstruction continues, and the pancreatitis persists and may worsen. Many studies support the value of urgent stone removal under these conditions.1 Whether surgery (duodenotomy, sphincterotomy, and stone extraction) or endoscopic sphincterotomy and stone extraction is used depends on availability of expertise. Most surgeons agree that the surgical approach is associated with higher morbidity and mortality, and recommend an endoscopic approach if skilled endoscopists are available. In most patients who have experienced an episode of biliary pancreatitis, the goals are to remove the gallbladder with its residual stones, and to rid the biliary ductal system of any residual stones that could cause another attack of pancreatitis. Laparoscopic cholecystectomy is preferred and is feasible in the majority of these cases. In patients with mild pancreatitis, this is usually performed 3 to 5 days after the initial hospitalization for pancreatitis when most or all of the symptoms have resolved. In patients with a severe episode of pancreatitis, a longer period of recovery (e.g., 2-3 weeks) as an outpatient is safer before cholecystectomy is done.2,3 The discussion about whether patients with biliary pancreatitis should undergo ERCP before surgery, and whether endoscopic stone extraction should be performed preoperatively if stones are found has been discussed in the article by Dr. Petelin elsewhere in this issue. NECROTIZING (HEMORRHAGIC) PANCREATITIS About 10% of patients with acute pancreatitis from any cause have a severe form of the disease associated with a significant degree of pancreatic necrosis. This is important because necrotizing pancreatitis (as opposed to the milder edematous form) is associated with higher morbidity and mortality, and because the treatment is often different. Generally, the outcome is related to whether the necrotic pancreas and peripancreatic tissue remains sterile or becomes infected. Most patients with sterile necrotizing pancreatitis require intensive medical therapy, but surgery is usually unnecessary. However, all patients with infected pancreatic necrosis require surgical drainage and debridement.4 Even in the most experienced hands, the mortality rate is 15% to 20%, but without surgery, almost all of these patients will die. Currently, there is no place for endoscopic (or transcutaneous) therapy involving tube drainage of the infected material. This is because the thick particulate nature of the necrotic tissue prevents its effective drainage through narrow lumen stents.