pancreatic necrosis complicating severe acute pancreatitis is a challenging scenario in contemporary critical care practice .
patients are often relatively young ( the median age was 55 years [ range 1974 years ] in a recent cohort report ) and postrecovery quality of life should be good , and so there is much to strive for . however , length of stay can be prolonged , and the evidence guiding treatment is limited and contradictory in nature . crucially , care for these patients involves close multidisciplinary cooperation because the margin for therapeutic error in decision making in relation to the timing and nature of intervention is small .
it is generally accepted that death from acute pancreatitis has a bimodal temporal distribution ; early deaths are related to multiple organ failure   and may in particular affect elderly patients , in whom decisions on thresholds for intervention may influence treatment and outcome . death from infected necrosis or the sequelae of peri - pancreatic sepsis
management of this group of patients is complex , but there has been a recent increase in the scope of available therapeutic options .
recent developments can be categorized into those directed at diagnosing infected necrosis , new pharmacological interventions and recent surgical trends .
the path finding study conducted by beger and coworkers   showed that the proportion of patients with pancreatic necrosis with evidence of bacterial colonization increased as the disease progressed .
infection of peripancreatic necrosis is relatively uncommon during the first 10 days of illness , and accordingly there is little to be gained by attempts at radiologically guided aspiration of fluid at this stage .
fine - needle aspiration of peripancreatic necrosis to look for evidence of infection comes into play between days 10 and 14 of the illness and , if negative , aspirates should be repeated at regular intervals thereafter .
the area to be targeted requires specific attention to detail . in the study conducted by beger and coworkers ,
fine - needle aspiration was directed at peripancreatic necrosis rather than at intra - abdominal fluid collections .
if patients have both , then they should be separately sampled and labelled as such .
newer methods used for detection of infected necrosis include measurements of biochemical markers such as calcitonin precursors .
procalcitonin is the 116 amino acid precursor of calcitonin ; it is released from neuroendocrine cells and detected in high concentrations in serum during severe bacterial or fungal infections .
elevated levels of procalcitonin correlate with disease severity , and there is some evidence of an association between procalcitonin levels and infection of necrosis .
use of genetic analytical techniques to quantify circulating bacteria derived gene products in plasma is interesting but not an established method .
patients receiving critical care are at high risk for developing infected necrosis and require serial imaging and aspiration of necrosis . it should be borne in mind that radiological ( computed tomographic ) findings such as the presence of gas can indicate infection .
it should also be remembered that a clinical diagnosis of infected necrosis based on fever , leucocytosis and other markers of sepsis without substantive proof of infection of necrosis can frequently be incorrect , and in turn may lead to potentially unnecessary surgery .
there remains no specific pharmacological treatment for infected necrosis , and the mainstay of treatment is drainage or debridement .
more recently , based on the results of the prowess ( recombinant human protein c worldwide evaluation in severe sepsis ) trial , drotrecogin alfa ( recombinant human activated protein c ) has been used in patients with sepsis . in an experimental model of acute pancreatitis ,
more pragmatically , when criteria for use of drotrecogin alfa are met in a patient with pancreatitis , it could be argued that the thrust of treatment should be to find and treat any intra - abdominal focus of infection [ 10 - 12 ] .
although these issues remain controversial , some consensus regarding the timing of surgical intervention is emerging .
early surgery for pancreatic necrosis is unprofitable because areas of necrosis will not yet have ' demarcated ' and the risk for haemorrhage is high . in practice , early laparotomy in severe acute pancreatitis can be justified in those individuals in whom there is concern about coexisting pathological processes , such as colonic ischaemia .
thus , a practical management plan emerges ; early pancreas - directed intervention is unprofitable , and surgery has a role to play only when it is needed to rule out coexisting disease . at the risk of adding complexity to this algorithm , we must consider the current trend toward measurement of intra - abdominal compartment pressure . an observational study of 293 patients with severe acute pancreatitis   demonstrated that early onset of organ dysfunction ( within 72 hours of onset of symptoms ) was associated with intra - abdominal hypertension ( defined as intra - abdominal pressure > 15 mmhg ) in 78% of patients .
this led to speculation about whether there is a role for early surgical intervention in the form of a ' decompressing ' laparotomy for raised intra - abdominal pressure .
a practical compromise is required here . ' decompressing ' laparotomy in patients without prior surgery carries a high risk for postoperative evisceration , intra - abdominal infection and colonization of previously sterile pancreatic necrosis , and can not be generally recommended .
intra - abdominal hypertension is due to fluid sequestration as a result of capillary endothelial injury , and thus there will be interstitial fluid in addition to free intra - peritoneal fluid .
however , in selected cases , in particular where diaphragmatic splinting may compromise ventilation , an argument can be made for decompression .
our group demonstrated that ' traditional ' surgical open necrosectomy , involving a long bisubcostal incision , extensive intra - abdominal mobilization and multiple drains , was a major surgical undertaking and associated with a worsening in organ failure scores during the immediate postoperative period . in light of this
the glasgow group pioneered minimally invasive necrosectomy    following a radiologically placed guide wire ( under general anaesthesia ) with a urological scope to effect debridement under irrigation .
various permutations of this procedure have been reported , and there is as yet no consensus on descriptive terminology or technique .
infected necrosis in which there is a predominance of solid and semisolid tissue in the peripancreatic area requires surgical debridement .
the available evidence suggests that ' less drastic ' surgery ( i.e. a mildine laparotomy , debridement , drainage and placement of a feeding jejunostomy ) is a safe and adequate option . to maintain a balanced perspective , it must be acknowledged that the minimally invasive procedures may be equally effective , but these are critically dependent on the expertise of the operator .
equally importantly , in those patients with pancreatic necrosis with a predominantly liquid collection , a pancreatic abscess can often be managed by radiological drainage ( which adheres to the principles outlined above ) and thus avoid surgery . in all cases
repeated intervention may be indicated , and the minimum requirement for contemporary care is the availability of radiological , critical care and pancreatic surgical expertise .
contemporary critical care management of the patient with pancreatic necrosis complicating acute pancreatitis is an area of relatively rapid change .
newer methods for detecting infection , new pharmacological interventions and more sophisticated surgery are all changing the face of care for this complex disease .
these developments should not obscure the importance of the underlying principle that patients with infected necrosis require debridement / drainage of their intra - abdominal focus of sepsis .
 pancreatic necrosis complicating severe acute pancreatitis is a challenging scenario in contemporary critical care practice ; it requires multidisciplinary care in a setting where there is a relatively limited evidence base to support decision making . 
 this commentary provides a concise overview of current management of patients with infected necrosis , focusing on detection , the role of pharmacologic intervention , and the timing and nature of surgical interventions . 
 fine - needle aspiration of necrosis remains the mainstay for establishment of infection . 
 pharmacological intervention includes antibiotic therapy as an adjunct to surgical debridement / drainage and , more recently , drotrecogin alfa . 
 specific concerns remain regarding the suitability of drotrecogin alfa in this setting . 
 early surgical intervention is unhelpful ; surgery is indicated when there is strong evidence for infection of necrotic tissue , with the current trend being toward ' less drastic ' surgical interventions . 
Introduction
Diagnosis of infected necrosis
Pharmacological intervention in infected necrosis
Timing and nature of surgical intervention
Conclusion
Competing interests