Diagnosis Of Infected Pancreatic Necrosis Research Articles

Diffusion weighted MRI and neutrophil lymphocyte ratio non-invasively predict infection in pancreatic necrosis: a pilot study.

Infected pancreatic necrosis (IPN) is a major determinant of mortality in acute pancreatitis (AP). Non-invasive diagnosis of IPN could guide the intervention in AP. We aimed to investigate the role of non-invasive methods like diffusion weighted magnetic resonance imaging (DW-MRI) and clinico-laboratory parameters as predictors of IPN. Prospective evaluation for predictors of IPN by diffusion restriction (DR) on DW-MRI and clinico-laboratory parameters was performed. Out of 39 patients included, 31 were analysed after exclusion. Twenty-six (83.8%) patients had moderately severe AP, and the rest had severe disease. They were categorized into Group A: patients with documented infection after intervention (n = 17) and Group B: successfully managed without intervention or negative culture after intervention (n = 14). On univariate analysis, Group A had significantly more incidence of fever (P = 0.020), persistent unwellness (P = 0.003), elevated neutrophil count (P = 0.007), lymphocyte count (P = 0.007), neutrophil lymphocyte ratio (NLR) (P = 0.028), DR on DW-MRI (P = 0.001) and low apparent diffusion coefficient (ADC) (P = 0.086). Multivariate analysis revealed DR on DW-MRI (P = 0.004) and NLR (P = 0.035) as significant predictors of IPN, among other factors. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DW-MRI were 94.1%, 78.6%, 91.66%, and 84.21%, respectively. The area under curve of NLR on the ROC plot was 0.85 and the best cutoff was >3.5, with sensitivity, specificity, PPV, and NPV of 70.6%, 78.6%, 80%, and 68.7% respectively. DW-MRI and NLR are promising non-invasive tools for accurate prediction of IPN and hence can guide the need for intervention in acute pancreatitis.

Appropriate Use of Antibiotics in Acute Pancreatitis: A Scoping Review.

While selective use of antibiotics for infected pancreatic necrosis (IPN) in acute pancreatitis (AP) is recommended, studies indicate a high rate of inadequate treatment. A search of PubMed, Scopus, and Cochrane databases was conducted, focusing on primary research and meta-analyses. Data were categorized based on core concepts, and a narrative synthesis was performed. The search identified a total of 1016 publications. After evaluating 203 full texts and additional sources from the grey literature, 80 studies were included in the review. The answers obtained were: (1) Preventive treatment does not decrease the incidence of IPN or mortality. Given the risks of bacterial resistance and fungal infections, antibiotics should be reserved for highly suspected or confirmed IPN; (2) The diagnosis of IPN does not always require microbiological samples, as clinical suspicion or computed tomography signs can suffice. Early diagnosis and treatment may be improved by using biomarkers such as procalcitonin and novel microbiological methods; (3) When indicated, early initiation of antibiotics is a key determinant in reducing mortality associated with IPN; (4) Antibiotics with good penetration into pancreatic tissue covering Gram-negative and Gram-positive bacteria should be used. Routine antifungal therapy is not recommended; (5) The step-up approach, including antibiotics, is the standard for IPN management; (6) Antibiotic duration should be kept to a minimum and should be based on the quality of source control and patient condition. Early antibiotic therapy is essential for the treatment of IPN, but prophylactic antibiotics are not recommended in AP. High-quality randomized controlled trials are required to better understand the role of antibiotics and antifungals in AP management.

Metagenomic next-generation sequencing, instead of procalcitonin, could guide antibiotic usage in patients with febrile acute necrotizing pancreatitis: a multicenter, prospective cohort study.

The effectiveness of procalcitonin-based algorithms in guiding antibiotic usage for febrile acute necrotizing pancreatitis (ANP) remains controversial. Metagenomic next-generation sequencing (mNGS) has been applied to diagnose infectious diseases. The authors aimed to evaluate the effectiveness of blood mNGS in guiding antibiotic stewardship for febrile ANP. The prospective multicenter clinical trial was conducted at seven hospitals in China. Blood samples were collected during fever (T ≥38.5°C) from ANP patients. The effectiveness of blood mNGS, procalcitonin, and blood culture in diagnosing pancreatic infection was evaluated and compared. Additionally, the real-world utilization of antibiotics and the potential mNGS-guided antimicrobial strategy in febrile ANP were also analyzed. From May 2023 to October 2023, a total of 78 patients with febrile ANP were enrolled and 30 patients (38.5%) were confirmed infected pancreatic necrosis (IPN). Compared with procalcitonin and blood culture, mNGS showed a significantly higher sensitivity rate (86.7% vs. 56.7% vs. 26.7%, P <0.001). Moreover, mNGS outperformed procalcitonin (89.5 vs. 61.4%, P <0.01) and blood culture (89.5 vs. 69.0%, P <0.01) in terms of negative predictive value. Blood mNGS exhibited the highest accuracy (85.7%) in diagnosing IPN and sterile pancreatic necrosis, significantly superior to both procalcitonin (65.7%) and blood culture (61.4%). In the multivariate analysis, positive blood mNGS (OR=60.2, P <0.001) and lower fibrinogen level (OR=2.0, P <0.05) were identified as independent predictors associated with IPN, whereas procalcitonin was not associated with IPN, but with increased mortality (Odds ratio=11.7, P =0.006). Overall, the rate of correct use of antibiotics in the cohort was only 18.6% (13/70) and would be improved to 81.4% (57/70) if adjusted according to the mNGS results. Blood mNGS represents important progress in the early diagnosis of IPN, with particular importance in guiding antibiotic usage for patients with febrile ANP.

Timing, approach, and treatment strategies for infected pancreatic necrosis: a narrative review

Timing, approach, and treatment strategies for infected pancreatic necrosis: a narrative review

Application of metagenomic next-generation sequencing for suspected infected pancreatic necrosis

BackgroundMetagenomic next-generation sequencing (mNGS) is increasingly used for the clinical diagnosis of infectious diseases, but there is a paucity of data regarding the application of mNGS in the early diagnosis of infected pancreatic necrosis (IPN). ObjectiveTo investigate the clinical application value of mNGS in the pathogenic diagnosis of IPN. MethodsForty-two patients with suspected IPN were prospectively and consecutively enrolled from August 2019 to August 2021. Blood samples were collected for mNGS and microbial culture simultaneously during fever (T ≥ 38.5 °C). For patients who had indications of surgical interventions, peri-pancreatic specimens were collected for mNGS and microbial culture simultaneously during the first surgical intervention to confirm IPN. The clinical performance of mNGS and microbial culture were compared. ResultsA total of 21 patients (50.0%) were confirmed to have IPN during hospitalization. The sensitivity of blood mNGS was significantly higher than blood culture (95.2% vs. 23.8%, P < 0.001) in diagnosing IPN. The negative predictive value of blood mNGS was 90.0%. The turnaround time of mNGS was significantly shorter than that of microbial culture [(37.70 ± 1.44) vs. (115.23 ± 8.79) h, P < 0.01] and the average costs of mNGS accounted for 1.7% of the average total cost of hospitalization. The survival analysis demonstrates that the positive blood mNGS result was not associated with increased mortality (P = 0.119). ConclusionsWith more valuable diagnostic performance and shorter turnaround time, clinical mNGS represents a potential step forward in the early diagnosis of IPN.

The Diagnosis and Treatment of Local Complications of Acute Necrotizing Pancreatitis in China: A National Survey.

Background The optimal management strategy in acute necrotizing pancreatitis (ANP) is debated, and compliance with current guidelines in China is not known. In this study, we performed a national survey on this topic in China. Methods An online questionnaire about the diagnosis and treatment of local complications of ANP was distributed through a national collaborative network. The local and systemic complications were defined according to the Revised Atlanta Classification. Results There were 321 survey respondents from the 394 who opened the link (response rate 81%) from 208 hospitals located in 30/34 provinces across China. There was a lack of consensus in terms of early diagnosis of infected pancreatic necrosis (IPN) as the respondents chose to depend on clinical symptoms (70/321, 22%), organ failure (82/321, 26%), imaging changes (84/321, 26%), and fine needle aspiration (51/321, 16%), respectively. A “step-up” approach has been widely adopted in patients with IPN (294/321, 92%). The decision for initial intervention (without confirmed/suspected infection) was based on clinical condition, CT imaging, or laboratory indicators for most respondents (229/321, 71%). Conclusion While the “step-up” approach has been widely adopted, there is still significant variation in regard to the diagnosis of infection, the best timing for drainage, and the indications for early intervention.

Indicators of volatile fatty acids for differential diagnostics of nfected of pancreatic necrosis complicated by retroperitoneal phlegmon.

The aim of the study was to assess the informative value of volatile fatty acid parameters for the differential diagnosis of infected pancreatic necrosis (IPN), complicated by retroperitoneal cellulitis. The work was based on the results of examination and treatment of 44 patients with infected pancreatic necrosis. The analysis of concentrations of volatile fatty acids: acetic, propionic, butyric and isovalerianic was carried out on a Kristallux-4000 automated gas chromatograph with an HP-FFAP capillary column and a flame ionization detector. The indicators of acetic acid and the amount of volatile fatty acids were statistically significantly higher in patients with infected pancreatic necrosis with total retroperitoneal phlegmons in comparison with the indicators of volatile fatty acids in patients with infected pancreatic necrosis with paracolic phlegmons and in comparison with indicators of volatile fatty acids in patients with infected pancreatic necrosis phlegmons. The indicators of acetic acid and the amount of VFA can be used as additional criteria for the differential diagnosis of IPN complicated by phlegmons of the retroperitoneal tissue.

Impact of prior antibiotics on infected pancreatic necrosis microbiology in ICU patients: a retrospective cohort study

BackgroundRecent guidelines advise against prophylactic antibiotics in patients with necrotizing pancreatitis, advocating instead a step-up drainage and necrosectomy strategy with antibiotics as dictated by microbiological findings. However, prompt antibiotic therapy is recommended in patients with sepsis or septic shock, a possible presentation of infected pancreatic necrosis (IPN). Consequently, in many critically ill patients with IPN, pancreatic samples are collected only after broad-spectrum antibiotic therapy initiation. Whether this prior antibiotic exposure alters the microbiological findings is unknown. The main objective was to determine whether prior antibiotic exposure sterilized the samples collected during procedures for suspected IPN in patients admitted to the intensive care unit (ICU) for acute pancreatitis with suspected IPN. We retrospectively studied 56 consecutive ICU patients admitted with suspected IPN. We collected details on the microbiological samples and antimicrobials used. A definite diagnosis of IPN was given when bacteria were identified in pancreatic samples.ResultsIn all, 137 pancreatic samples were collected, including 91 (66.4%) after antibiotic therapy initiation. IPN was confirmed in 48 (86%) patients. The proportion of positive samples was 74 (81.3%) in antibiotic-exposed patients and 32/46 (69.5%) in unexposed patients (p = 0.58). Of the 74 positive samples from exposed patients, 62 (84%) had organisms susceptible to the antibiotics used. One-third of samples contained more than one organism. Among patients with IPN, 37.5% had positive blood cultures. Multidrug- or extensively drug-resistant bacteria were identified at some point in half the patients. Enterobacter cloacae complex was more frequent in the exposed group (p = 0.02), as were Gram-negative anaerobic bacteria (p = 0.03).ConclusionAntibiotic exposure before sampling did not seem to affect culture positivity of pancreatic samples to confirm IPN, but may affect microbiological findings. Our results suggest that, in patients with sepsis and suspected IPN, antibiotics should be started immediately and pancreatic samples obtained as soon as possible thereafter. In other situations, antibiotics can be withheld until the microbiological results of pancreatic samples are available, to ensure accurate targeting of the spectrum to bacterial susceptibility patterns.ClinicalTrials.gov number NCT03253861

The volatile fatty acids indicators in the differential diagnosis of purulent complications of pancreatic necrosis.

The purpose of the study was to evaluate the informative value of volatile fatty acid (VFA) indicators for the differential diagnosis of infected pancreatic necrosis (IPN), complicated by retroperitoneal cellulose phlegmons and IPN, complicated by pancreatic abscesses. The work is based on the results of the examination and treatment of 52 patients with IPN, complicated by abscesses and phlegmon. The analysis of the concentrations of acetic, propionic, butyric and isovaleric acids were carried out on the gas chromatograph "Crystalllux-4000" with the capillary "HP-FFAP" column. Indicators of acetic, propionic, butyric acids and the amount of VFA were statistically significantly higher in patients with IPN, complicated by retroperitoneal cellulose phlegmons, compared with those of VFA in patients with IPN, complicated by pancreatic abscesses. Indicators of acetic acid and the amount of VFA were statistically significantly higher in patients with IPN, complicated by parapancreatic phlegmon, compared with those of VFA in patients with IPN, complicated by pancreatic abscesses. Indicators of acetic, propionic, butyric, isovaleric acid and the amount of VFA were statistically significantly higher in patients with IPN, complicated by paracolic phlegmon, compared with atients with IPN, complicated by pancreatic abscesses. Indicators of acetic, propionic, butyric acids and the amount of VFA were statistically significantly higher in patients with IPN, complicated by total retroperitoneal phlegmon, compared with patients with IPN, complicated by pancreatic abscesses. The values of VFA can be used as additional criteria for the differential diagnosis between IPN, complicated by retroperitoneal phlegmon and IPN, complicated by pancreatic abscess.

Selective Necrosectomy for Infected Pancreatic Necrosis

Background: Until recently, a diagnosis of infected pancreatic necrosis (IPN) warranted necrosectomy, which was associated with high morbidity and mortality rates greater than 20%. Preoperative percutaneous drainage delayed the need for necrosectomy with improved outcomes. Methods: In 2008, this institution changed its approach to the management of such cases opting instead for percutaneous drainage with selective deferred necrosectomy. A total of 38 consecutive patients with IPN from January 2008 to December 2014 were included. Results: All 38 underwent percutaneous radiological drainage, and selective necrosectomy was performed on 15 where the infected necrosis did not completely resolve. Twenty-three patients did not require surgery and were managed with pancreatic drain insertion, optimal nutritional support and critical care interventions. Median peak Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores were 10 (range 0-18) and 3 (range 0-10) prior to radiological intervention. Overall mortality was 5% (n = 2). Conclusion: This study demonstrates that radiological-guided drainage of infected pancreatic collections can, in most cases, prove curative and, if not, facilitates delayed surgical intervention with improved outcomes.

Negative pressure irrigation and endoscopic necrosectomy through man-made sinus tract in infected necrotizing pancreatitis: a technical report.

BackgroundIn recent years, a step-up approach based on minimally invasive techniques was recommended by latest guidelines as initial invasive treatment for infected pancreatic necrosis (IPN). In this study, we aimed to describe a novel step-up approach for treating IPN consisting of four steps including negative pressure irrigation (NPI) and endoscopic necrosectomy (ED) as a bridge between percutaneous catheter drainage (PCD) and open necrosectomyMethodsA retrospective review of a prospectively collected internal database of patients with a diagnosis of IPN between Jan, 2012 to Dec, 2012 at a single institution was performed. All patients underwent the same drainage strategy including four steps: PCD, NPI, ED and open necrosectomy. The demographic characteristics and clinical outcomes of study patients were analyzed.ResultsA total of 71 consecutive patients (48 males and 23 females) were included in the analysis. No significant procedure-related complication was observed and the overall mortality was +21.1 % (15 of 71 patients). Seven different strategies like PCD+ NPI, PCD+NPI+ED, PCD+open necrosectomy, etcetera, were applied in study patients and a half of them received PCD alone. In general, each patient underwent a median of 2 drainage procedures and the median total drainage duration was 11 days (interquartile range, 6–21days).ConclusionsThis four-step approach is effective in treating IPN and adds no extra risk to patients when compared with other latest step-up strategies. The two novel techniques (NPI and ED) could offer distinct clinical benefits without posing unanticipated risks inherent to the procedures.Electronic supplementary materialThe online version of this article (doi:10.1186/s12893-016-0190-x) contains supplementary material, which is available to authorized users.

DECISION SUPPORT SYSTEMS IN THE DIAGNOSIS AND TREATMENT OF ACUTE PANCREATITIS

This paper is a systematic review of literature covering the use of decision support systems in the diagnosis and treatment of acute pancreatitis. The authors provide modern literature data on the efficacy of different support systems for decision-making based on artificial neural networks to determine the severity of acute pancreatitis outcomes, prognosis and diagnosis of infected pancreatic necrosis.

Диагностика инфицированного панкреонекроза на основании оценки показателей эндотелиальной дисфункции

Диагностика инфицированного панкреонекроза на основании оценки показателей эндотелиальной дисфункции

Decision support system for diagnosis of infected pancreatic necrosis

s / Pancreatology Unit of General Surgery B, Pancreas Institute, “G.B. Rossi” Hospital, University of Verona Hospital Trust, Italy Background: Pancreatic texture has been identified as one of the most important risk factors for postoperative pancreatic fistula after partial pancreatectomy. Texture definition (classically soft/hard) is however subjective and based on intraoperative gland palpation. Objective: to develop a reproducible method for the assessment of pancreatic texture by using elastic module measurement. Methods: Study population consisted of 140 patients who underwent pancreatic resections at our institution from November 2010 to November 2011. Before pancreatic transection, a calibrated coiled valvewas employed to test pancreatic resistance to compression. Texture was expressed by using pancreatic elastic module (Newton/mm2). Measurements were then correlated with a pathologic score (0-100) based on percentage of fibrosis, pancreatic acini and fat infiltration of the resection margin. Furthermore, the pancreas was palpated by an experienced surgeon (blinded to the elastic module measurement) who subjectively assessed texture on a 1-to10 scale. Results: There was a significant correlation between pancreatic elastic module and pathologic score (p1⁄40.005). In order to define “soft” and “hard” texture, an arbitrary cut off was set at the 75th percentile for pathological score (Total amount of fibrosis >45%). Mean values of elastic modules for soft/hard pancreas did differ significantly (p<0.001), and – surprisingly – surgeon's manual evaluation correlated with both elastic module and pathological assessment. Conclusions: Pancreatic texture can be assessed using elastic module. This is a reproducible method which may represent a common framework for future multicentric studies. The next step of this analysis will be the correlation between pancreatic texture assessed by elastic module and the development of postoperative pancreatic fistula.

Rational Use of Antimicrobials in Patients with Severe Acute Pancreatitis

Infectious complications in severe acute pancreatitis are associated with considerable morbidity and mortality. The course of the disease is often protracted, and patients often stay in the hospital for several weeks. Diagnosis of infected pancreatic necrosis is difficult, and the treatment consists of source control and antibiotic treatment. Antibiotic use should be rational in terms of a rational indication, a rational spectrum, and a rational duration. Prophylactic antibiotics are not effective in reducing the incidence of (peri)-pancreatic infection in patients with severe disease (or even documented necrotizing pancreatitis). The only rational indication for antibiotics is documented infection. The spectrum of empirical antibiotics should include both aerobic and anaerobic gram-negative and gram-positive microorganisms. Also, fungal infections are often present in these patients, and antifungal coverage or even prophylaxis should be considered, especially if multiple risk factors for invasive candidiasis are present. Although initiation of antibiotics may be a difficult decision, stopping antibiotic therapy often proves to be even more difficult. Currently, no tools are available to guide antimicrobial treatment. Antibiotic use is only effective if proper source control has been established.

DIAGNOSIS OF INFECTED PANCREATIC NECROSIS ON THE BASIS ANALYSIS OF CT-IMAGES ANISOTROPY

The paper is dedicated to a vital topic of emergency surgery, diagnosis of infected pancreatic necrosis. The authors have developed and have analysed clinical efficiency of the new method of differential diagnosis of sterile and infected pancreatic necrosis using CT image data. The method is based on the quantitative estimation of the anisotropy features of pancreas texture. The developed method of CT-data analysis has praved to be sufficiently precise for the diagnosis of pancreatic infection.

The clinical effectiveness of percutaneous drainage and laparotomy for patients with infective pancreatic necrosis

To compare the clinical effectiveness of percutaneous US- or CT-guided drainage and laparotomy for patients with infective pancreatic necrosis. Data of 90 infective pancreatic necrosis patients admitted from January 2008 to December 2009 were included. They were divided into two groups by the different treatment choices. Twenty-seven patients in the percutaneous group received percutaneous US- or CT-guided drainage as first choice. After that a sump suction apparatus was applied for controlled drainage. If no improvement was achieved after 3 days, they would received operation soon. While patients in the laparotomy group received surgical drainage at the time when the diagnosis of infected pancreatic necrosis was confirmed. Continuous drainage was also applied for these ones. The percutaneous group had a significant low rate of reoperation (7.1% vs. 14.3%, P < 0.05) and postoperative residual abscesses (7.1% vs. 28.6%, P < 0.05). Furthermore, 48.1% of patients in percutaneous group successfully avoid laparotomy. In the regard of complications, the percutaneous group presented lower incidence of both single organ dysfunction (7.4% vs. 28.6%, P < 0.05), intestinal fistula (7.4% vs. 27.0%, P < 0.05) and long-term complications (3.7% vs. 22.2%, P < 0.05). In addition, the percutaneous group costed less medical resources as evidenced by shorter ICU duration (21.2 ± 9.7 vs. 28.7 ± 12.1, P < 0.01), shorter hospital duration (48.2 ± 12.5 vs. 59.6 ± 17.5, P < 0.05) and less expenditure (191 762 ± 5892 vs. 341 689 ± 10 854, P < 0.05). Percutaneous drainage can effectively lower the surgical rates and the rates of complications and reoperations in patients with infective pancreatic necrosis. Besides that, it could also reduce the cost of medical resources.

Primary Conservative Treatment Results in Mortality Comparable to Surgery in Patients With Infected Pancreatic Necrosis

The standard treatment for patients with infected pancreatic necrosis (IPN) is surgical necrosectomy. We compared the outcomes of surgical treatment versus primary conservative treatment (patients kept in intensive care unit and treated with antibiotics, organ support, intensive nutritional support, and, if required, percutaneous drainage) among patients with IPN. We performed retrospective comparative (with prospectively acquired database) and prospective observational studies; data were collected from all consecutive patients with acute pancreatitis (n = 804), and those with IPN formed the study group. Patients with IPN were divided into 2 groups on the basis of diagnosis of IPN during 1997-2002 (group 1, n = 30) or 2003-2006 (group 2, n = 50). Eighteen patients in group 1 were treated by surgical necrosectomy, and 40 patients in group 2 were given primary conservative treatment; surgery was performed on patients if conservative treatment failed (n = 10). The primary outcome measure was mortality. The mortality was comparable in group 1 versus group 2 (43% vs 28%; P = .22). During a period of 10 years, the patients who received primary conservative treatment had significantly higher survival rates than those who received surgery (76.9% vs 46.4%; P = .005). In the prospective study during 2007-2008, the mortality from infected necrosis was 29.6% after primary conservative treatment, confirming the results of the comparative study. In treating patients with IPN, a primary conservative strategy resulted in mortality that was comparable with that after surgery, and 76% of the patients were able to avoid surgery; 54.5% of IPN patients were successfully managed with the primary conservative strategy.

Use of antibiotics in severe acute pancreatitis

Infectious complications in severe acute pancreatitis are an important problem and determine outcome in patients who survived the first inflammatory hit of the disease. Timely diagnosis of infected pancreatic necrosis is often challenging, but should not delay adequate treatment, which consists of source control and antibiotic treatment. Prophylactic antibiotics are not effective in reducing the incidence of (peri)pancreatic infection in patients with severe acute pancreatitis (or necrotizing pancreatitis). The only rational indication for antibiotics at this moment is documented infection. The spectrum of empiric antibiotics should cover both Gram-negative, Gram-positive and anaerobic microorganisms (also keeping in mind exposure to nosocomial microorganisms), and local ecology should be taken into account. Fungal infections are often present, and antifungal coverage should be considered, especially if multiple risk factors for invasive candidiasis are present. Currently, no tools are available to guide antimicrobial treatment.

Therapeutic intervention and surgery of acute pancreatitis

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.