The
clinical course of
acute pancreatitis varies from mild to severe. Assessment of severity and etiology of
acute pancreatitis is important to determine the strategy of management for
acute pancreatitis.
Acute pancreatitis is classified according to its morphology into edematous
pancreatitis and necrotizing
pancreatitis. Edematous
pancreatitis accounts for 80-90% of
acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing
pancreatitis occupies 10-20% of
acute pancreatitis and the mortality rate is reported to be 14-25%. The mortality rate is particularly high (34-40%) for infected
pancreatic necrosis that is accompanied by
bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148-154, 1993; Ogawa et al. in Research of the actual situations of
acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry of Health, Labour, and Welfare. Heisei 12 Research Report, pp 17-33, 2001). On the other hand, the mortality rate is reported to be 0-11% for sterile
pancreatic necrosis which is not accompanied by
bacterial infection (Ogawa et al. 2001; Bradely and Allen in Am J Surg 161:19-24, 1991; Rattner et al. in Am J Surg 163:105-109, 1992). The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of
acute pancreatitis in patients having a variety of clinical characteristics. This article describes the guidelines for the surgical management and interventional
therapy of
acute pancreatitis by incorporating the latest evidence for the management of
acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood
endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected
pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected
pancreatic necrosis; (3)
conservative treatment should be performed in sterile
pancreatic necrosis; (4) infected
pancreatic necrosis is an indication for interventional
therapy. However,
conservative treatment by
antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing
pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a
surgical procedure for infected
necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the
stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and
surgical procedure should be performed for pancreatic
abscess; (9) if the clinical findings of pancreatic
abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for
pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of
cysts and (11) percutaneous drainage, endoscopic drainage or
surgical procedures are selected in accordance with the conditions of individual cases.