As discussed by Drs. Mantke and Lippert, the management of severe acute pancreatitis has changed markedly over the last several decades as we have come to understand more about the development and progression of necrotizing pancreatitis. Probably the biggest change/advance has been the move from an initial early and aggressive operative intervention/necrosectomy (Beger et al. 1982; Farrugia et al. 1993) to one of a more supportive, observational attempt at avoiding, if possible, any operative or interventional procedure in patients with sterile necrosis and delaying the timing of operative intervention to 3-4 weeks after onset of the disease, even in those with infected necrosis (Kendrick and Sarr 2005). This latter approach involves the use of targeted antibiotic treatment in patients with documented infected necrosis to prevent the systemic bacteremia and overwhelming sepsis and thereby to allow the local area(s) of infected necrosis to become walled off by the host response. By doing so, the eventual operative approach allows again a targeted necrosectomy in a contained area with much less postoperative morbidity and mortality. In addition, some patients avoid any operative or even radiologic intervention, because the disease process resolves spontaneously; how often such a phenomenon occurs, however, is unknown despite anecdotal reported experience (Runzi et al. 2005; Garg et al. 2010; Sarr and Seewald 2010).
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