Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course to a rapidly progressive, severe illness. The mortality rate of severe
acute pancreatitis exceeds 20%, and some patients diagnosed as mild to moderate
acute pancreatitis at the onset of the disease may progress to a severe, life-threatening illness within 2-3 days. The Japanese (JPN) guidelines were designed to provide recommendations regarding the management of
acute pancreatitis in patients having a diversity of clinical characteristics. This article sets forth the JPN guidelines for the surgical management of
acute pancreatitis, excluding
gallstone pancreatitis, by incorporating the latest evidence for the surgical management of severe
pancreatitis in the Japanese-language version of the evidence-based Guidelines for the Management of
Acute Pancreatitis published in 2003. Ten guidelines are proposed: (1) computed tomography-guided or ultrasound-guided fine-needle aspiration for bacteriology should be performed in patients suspected of having infected
pancreatic necrosis; (2) infected
pancreatic necrosis accompanied by signs of
sepsis is an indication for surgical intervention; (3) patients with sterile
pancreatic necrosis should be managed conservatively, and surgical intervention should be performed only in selected cases, such as those with persistent organ complications or severe
clinical deterioration despite maximum
intensive care; (4) early surgical intervention is not recommended for necrotizing
pancreatitis; (5) necrosectomy is recommended as the
surgical procedure for infected
pancreatic necrosis; (6) simple drainage should be avoided after necrosectomy, and either continuous closed lavage or open drainage should be performed; (7) surgical or percutaneous drainage should be performed for pancreatic
abscess; (8) pancreatic
abscesses for which clinical findings are not improved by percutaneous drainage should be subjected to surgical drainage immediately; (9)
pancreatic pseudocysts that produce symptoms and complications or the diameter of which increases should be drained percutaneously or endoscopically; and (10)
pancreatic pseudocysts that do not tend to improve in response to percutaneous drainage or endoscopic drainage should be managed surgically.