*4.2.3.3 Open surgical necrosectomy*

If these methods are unable to control the infectious condition, the patient's deterioration, despite good drainage, including minimally invasive surgical drainage, would be indicated to the open surgical approach. The mortality of patients with infected necrosis is greater than 30%, as we have commented, the delay in surgery as much as possible will be more beneficial for the patient in terms of mortality and morbidity. Early debridement, and especially sterile necrosis, leads to a significant increase in mortality. Therefore, these techniques are reserved when everything else has not been enough [36–37]. We have widely described open necrosectomy techniques. None of them has been shown to be clearly superior to the other due to the lack of randomized studies, but the ones that offer the best results are:


Vacuum Assisted Closure therapy will be used as a temporary closure in cases where closure of the abdominal pare is impossible or in cases of abdominal compartment syndrome.

Current comparative studies, with the exception of randomized trials [18], should be interpreted with caution, given the severity of the often higher disease in


**Table 3.**

*Ramson and Glasgow prognostic scale.*

patients undergoing open debridement. Open debridement is indicated in patients with a high necrosis load that is diffusely distributed throughout the abdomen and that do not respond to staggered handling [32].

RAMSON: Prognostic scale in acute pancreatitis (**Table 3**).

GLASGOW: Prognostic scale in acute pancreatitis (**Table 3**).

Zero to do criteria met indicates mild pancreatitis; 3 or more criteria severe pancreatitis.

According to the number of criteria the rate of mortality is: 0–2 mortality >2%; 3–5 mortality 10–20%; 6–7 mortality 50–60%; > 7 mortality 70–90%.

### **5. Conclusions**

Patients with diagnosis of acute necrotizing pancreatitis should be treated in centers with high experience by specialists in pancreatic surgery, endoscopists and radiologist experienced. It is essential the presence of a team of intensive doctors or anesthesiologists especially in the first weeks of evolution. Despite these measures the morbidity and mortality in these patients is still high, so we must try to reduce it with a correct management and applying the "step up approach". The sequential treatment is an alternative to open necrosectomy, including percutaneous drainage, endoscopic (transgastric) drainage, and minimally invasive retroperitoneal necrosectomy. With this approach, up to 35% of patients can be treated only with drainage, to avoid necrosectomy and to reduce the percentage of complications.

### **Acknowledgements**

Our thanks to the Biliopancreatic Surgery Unit that through effort and study have created a protocol for the management of severe pancreatitis. The team

*Necrotizing Pancreatitis: Step Up Approach DOI: http://dx.doi.org/10.5772/intechopen.96196*

is made up of expert pancreatic surgeons, intensivist physicians, anesthesiologists, endoscopists with experience in echoendoscopy and radiologists specializing in the abdomen. Together we will continue to train for the good of our patients.
