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Necrosectomy with postoperative continuous local lavage was performed in a prospective study involving 95 patients with necrotizing pancreatitis. In the same period 567 patients with oedematous-interstitial pancreatitis were treated non-operatively with a hospital mortality rate of 0.7 per cent. In patients with necrotizing pancreatitis the median Ranson criteria score was 4.5 points; operation was required at a median of 7 days after the onset of symptoms because of non-response to conservative treatment. In all, 59 per cent of the patients (56 out of 95) developed extended intrapancreatic parenchymal necrosis, 70 per cent had ascites, and 66 per cent had intra- and extrapancreatic necrosis; 42 per cent of the patients had bacterial infection of the necrotic tissue. For lavage a median of 8 l/24 h of fluid were instilled postoperatively for 25 days (median). The lavage fluid showed high levels of immunoreactive trypsin, phospholipase A2, and endotoxin in the early postoperative period. Hospital mortality rate was 8.4 per cent. Necrosectomy and continuous postoperative lavage can achieve high survival rates in patients with necrotizing pancreatitis. Postoperative local lavage allows the continuous non-operative evacuation of biologically active compounds and devitalized tissue, and avoids damage to remaining vital exocrine and endocrine pancreatic tissue.

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SUMMARY One hundred and five of 395 patients with acute pancreatitis were surgically treated in our clinic from 1981 to 1984. Ninety three of these patients were examined with contrast enhanced computed tomography and/or ultrasound and were clinically assessed according to Ranson's objective criteria before operation. At operation, 77 patients showed necrotising pancreatitis and 16 showed biliary acute interstitial pancreatitis. Ninety per cent of the cases with extensive and 79% of those with minor necroses of the pancreas had been demonstrated with contrast enhanced computed tomography. Ultrasound failed to be diagnostic in 24% of the patients due to meteorism; the sensitivity of the diagnostic studies for pancreatic necrosis was 73% regardless of the extent of the process. Using the early objective signs, seven patients with acute interstitial pancreatitis were classified as having a severe attack, whereas 30 patients with necrotising pancreatitis were categorised as mild attacks. We conclude that the contrast enhanced computed tomography is an aid in deciding on conservative or surgical treatment in a case of acute pancreatitis. Ultrasound does not appear to be an adequate method for determining pancreatic necrosis. The early objective signs fail to sufficiently identify the necrotising form of acute pancreatitis.Even severe cases of acute pancreatitis can be cured by medical therapy if they are restricted to interstitial inflammation. Necrotising pancreatitis, however, holds a high risk of local infection and generalised sepsis and can, if it involves larger areas of the pancreas, lead to retroperitoneal tissue invasion and progressive toxic organ complications. 1-3 These complications could be avoided by the surgical removal of necrotic tissue and exudate.2-This in turn poses the problem of identifying and quantifying the necrosis of the pancreas in time for a successful operation. We therefore conducted a prospective clinical study in which the capacity of contrast enhanced computed tomography, ultrasound, and early objective signs7 to assess necrotising pancreatitis was determined by comparing the

In 205 patients with necrotizing pancreatitis, surgery was carried out following failure of medical treatment. Intraoperatively, according to the size of the necrotic area and the weight of the surgically removed necrotic tissue, 79 patients showed a limited panereatic necrosis, and 126 patients an extended necrotizing process. In 40.4% of 138 patients with bacteriological reports, a bacterial contamination of the pancreatic necrosis was found. The main objective of surgical management was the removal of the necrotic tissue. This was performed with 2-way drainage and postoperative continuous peritoneal and/or local lavage, in a smaller group of patients with inner drainage of the necrosis cavity, and in a few patients with drainage alone. The overall hospital mortality rate was 24.4%. The Iowest mortality was achieved in patients treated with necrosectomy and postoperative continuous local lavage (6.0%). In patients with necrosis of approximately 30% of the pancreas, mortality was lower (7.6%) than in patients with a 50% necrosis (24.0%) or in patients with a subtotal/total necrosis (51.0%) (p < 0.0001). Formation of extrapancreatic necrosis resulted in a significantly increased mortality rate (p < 0.02). In patients with bacterially contaminated necrosis, a mortality rate of 32.1% was found, whereas in patients with a steri|e neerosis, mortality was down to 9.8% (p < 0.01). Based on the results of this study, we eonclude that the clinical course of necrotizing pancreatitis depends essentially on the extent of the necrosis in the pancreas itself, the development of extrapancreatic necrosis, and the bacteriological status of the necrotic area. Adequate surgical management leads to a considerably increased survival rate of patients with necrotizing pancreatitis.