Background: The course of acute pancreatitis (AP) is unpredictable and can vary from mild to lethal. Mortality varies from low (<2%) in mild cases to high (20%-70%) in the case of infected pancreatic necrosis. Surgical management has not been investigated in well-designed trials. Based on literature review and retrospective results from our institution, recent insights are summarized and recommendations concerning surgical treatment of AP are given.

Methods: Data of patients who underwent necrosectomy for AP in our hospital in the period 1988-2001 were reviewed. Surgical treatment strategy was divided into open abdomen strategy (OAS) and primary closure with continuous postoperative lavage (CPL). An extensive database literature search was performed to obtain articles on surgical management of AP. Level 5 evidence articles were excluded.

Results: In our institution, 38 patients were treated with OAS and 21 with CPL. Mortality was high (47% in the OAS group and 33% in the CPL group). The primary cause of mortality was multiorgan failure. Only 50 manuscripts from the literature search contained useful data. Mortality of patients with OAS and CPL treatment was 27% and 15%. respectively. Fewer cases of gastro-intestinal fistulas. bleeding and re-interventions were reported with CPL. The majority of all survivors regained a good quality of life.

Conclusion: Mortality of acute necrotizing pancreatitis remains high, despite optimal surgical and medical treatment. Current surgical practice is not based on well-designed clinical trails. Randomized studies are needed to define evidence-based surgery in acute necrotizing pancreatitis.