Treatment of severe acute pancreatitis and its complications

Table 1 Computer tomography indeks of illness severity for acute pancreatitis[48]

Computer tomography findings	Grade	Score
Balthazar
Normal pancreas	A	0
Enlargement	B	1
Inflammation of pancreas and fat	C	2
Single fluid collection	D	3
Two or more fluid collections	E	4
Necrosis
< 30%		2
30%-50%		4
50%		6
	Max = 10 points

Table 2 Principles of intensive monitoring and systemic support

Parameters
Intensive invasive monitoring of vital constants
Analgesics (consider epidural analgesia if necessary)
Fluid resuscitation with monitoring of central venous pressure
Electrolyte solutions
Plasma expanders
Humidified oxygen administration
Catecholamines (dopamine, dobutamine)
Early nutritional support
Early treatment of systemic complications
Mechanical ventilation with positive end-expiratory pressure
Catecholamines (epinephrine)
Hemofiltration, dialysis
Insulin and calcium substitution

Table 3 Surgical treatment modalities in necrotizing pancreatitis[86]

Surgical treatment modalities
Open necrosectomy with open packing - after necrosectomy, the abdomen maybe left open and repeatedly debrided until there is no residual necrosis, and is allowed to close by secondary intention
Open necrosectomy with closed packing - after the removal of necrotic tissue, the abdomen is closed, packing with external drains left in place. The drains are removed singly every other day, starting 5-7 d postoperatively
Open necrosectomy with continous postoperative lavage - the procedure is based on the insertion of 2 or more double lumen catheters. Repeated open necrosectomy is performed and the packing is removed when there is no residual necrosis. The smaller lumen of the drains is used for the inflow of the lavage, and the larger lumen is used for the outflow. The drains can be removed after 2-3 wk
Programmed open necrosectomy - necrosectomy of necrotic tissue is performed using multiple procedures. After necrosectomy, the pancreatic bed is packed with sponges and soft drains are placed on the top of the packs. The abdomen is closed using a zipper