Surgical Strategies in Severe Acute Pancreatitis (SAP): Indications, Complications and Surgical Approaches

Background: Severe acute pancreatitis (SAP) is still related to high mortality rates. This study evaluated the various surgical strategies for treatment of suspected infected necroziting pancreatitis (INP). Methods: This retrospective study included 212 patients with SAP and INP, who had surgical treatment during the period between January 2000 - December 2012 at the Ist Surgical Clinic. Surgical approaches included laparostomy with continous postoperative retropancreatic lavage, open abdomen strategy, laparotomy with primary abdominal closure accompanied or not by laparostomy (marsupialization), retroperiostomy with retroperitoneal lavage. Results: The overall mortality rate was 34.0 percent, with 24 percent in laparotomy with continous retropancreatic lavage, 11 percent for retroperitoneostomy and retroperitoneal continous lavage, 71 percent for the open abdomen strategy, and 43 percent for laparotomy with closed abdomen (p<0.001). Acute operations, alcoholic origin, Apache II scores of >= 10 organ dysfunction on admission were independent factors that predisposed patients to complications. Colonic necrosis with high mortality rates (53 percent), however seemed to be of prognostic relevance. Conclusions: The conservative approach in severe acute pancreatitis is a promising therapeutic concept. Delaying surgery up to the third week after onset of disease significantly improves the patients' survival. Complications are common in severe necrotizing pancreatitis leading to organ failure and need for acute operations. Colonic necrosis is an independent prognostic factor for survival.