A comprehensive management plan is presented for patients with severe
acute pancreatitis. These patients may have pancreatic or peripancreatic
necrosis or pancreatic fluid collections.
Multiple organ failure often develops in patients with severe
pancreatitis. We therefore recommend that all patients with
acute pancreatitis be evaluated for pancreatic anatomy and function. If a patient is seriously ill, a computed tomographic (CT) scan with vascular enhancement should be done. Meanwhile, vigorous fluid replacement is necessary using Swan-Ganz monitoring. Patients with
necrosis do not need surgical intervention unless the
clinical course or CT scan-guided aspiration shows
infection. The objective of an operation should be to remove all infected tissue and fluid. A preoperative CT scan with vascular enhancement should be used as a guide during the operation to ensure that all foci of infected
necrosis or fluid are eliminated. We have found that open packing and irrigation with
sodium oxychlorosene are helpful in patients with extensive
necrosis or those who become infected early after the onset of symptoms. In all, 40% to 50% of patients treated by closed drainage will require reoperation because of incomplete
debridement. Persistent
sepsis is an indication for reoperation.