Indications ■ Pancreatic and/or peripancreatic necrosis (based on contrast-enhanced dynamic CT
scan) complicated by documented infection (guided FNA culture or extraluminal retroperitoneal gas).
■ Sterile necrosis with progressive clinical deterioration despite maximal medical treatment; an aggressive operative approach in the absence of documented infection is, however, controversial.
■ Timing: Necrosectomy should be undertaken as late as possible after onset of disease, when the necrotic process has ceased, viable and nonviable tissues are well demarcated, and the infected necrotic tissues are better organized and "walled off."
■ Operative necrosectomy for patients greater than 3-4weeks after onset of disease who are not improving and cannot eat but who have documented "sterile necrosis" remains controversial - some groups maintain that recovery is speeded with necrosectomy; others maintain a nonoperative approach ultimately proves safer.
■ Massive hemorrhage or bowel perforation (colon, duodenum).
Contraindications ■ Pancreatic and/or peripancreatic necrosis without evidence of infection or clinical deterioration.
■ Early operation (within lweek from onset of acute pancreatitis) before the systemic inflammatory response syndrome (SIRS) has subsided and maximal intensive medical treatment is still necessary. Hemodynamic and metabolic instability early after necrotizing pancreatitis is secondary to SIRS and not to bacterial sepsis.
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