図２と図３で体部と尾部は，脾臓と比べて造影の程度はやや弱いが膵組織として認識できる（△）から壊死はないが，図２〜図４の頭部は膵組織を認識できない程に低濃度となっており（▲）壊死を強く疑う．図５と図６の頭部の一部（△）は膵組織として認識できviableな膵組織と判断する．
　下段の図A〜図Eは48時間後のCT． 48時間経過すると壊死部分とviableな膵組織（△）がはっきりしてくる．▲は均一な低濃度を呈し，頭部の壊死であり，わずかの組織が生き残っているだけである（図C〜図E：△）．図CとDで膵壊死部にガスが存在する（↑）が，膵壊死部が感染するのは通常10日〜2週間後であり，3日以内でガスを認識することは腸管（十二指腸が最も可能性が高い）壊死による瘻孔を強く示唆する．Du：十二指腸．来院時のCT図２でもそうだが，48時間後の図AでIVCは平坦なままであり，十分な輸液が投与されていない．強い脱水状態が膵壊死を助長した可能性は否定できない．敗血症や腹腔内出血など種々の合併症を併発し3ヶ月後に死亡した．

参考症例（慢性膵炎の急性増悪・膵頭部壊死）：33歳男性．軽症のアルコール性膵炎で3回の入院歴がある．膵頭部に石灰化を認め（白矢印）慢性膵炎の急性増悪である．膵頭部で△はviableな膵組織だが，▲は造影効果を認めず，頭部の部分壊死である．最下段の，8日目のCTでは壊死部が液化し嚢胞状となった（↑）が，一部は残存している（△）．保存的療法で嚢胞所見は縮小し3週間で治癒した．

文献考察：膵壊死の手術（necrosectomy）の死亡率は28％．ほとんど全例で術後合併症を伴う．
Surgery. 2005 May;137(5):499-505.
Early and late complications after pancreatic necrosectomy.
Connor S, Alexakis N, Raraty MG, Ghaneh P, Evans J, Hughes M, Garvey CJ, Sutton R, Neoptolemos JP.

BACKGROUND: Surgery for pancreatic necrosis is associated with a high morbidity and mortality. The aim of this study was to review the incidence of early and late complications after pancreatic necrosectomy in a large contemporary series of patients. METHODS: The clinical outcomes of 88 patients who underwent pancreatic necrosectomy between 1997 and 2003 were reviewed. RESULTS: The median age was 55.5 (range, 18-85) years, 54 (61%) were males, 68 (77%) had primary pancreatic infection, 71 (81%) had >50% necrosis, and the median admission Acute Physiology and Chronic Health Evaluation score was 9 (range, 1-21). Median time to surgery was 31 (range, 1-161) days; 47 patients underwent minimally invasive necrosectomy and 41 open necrosectomy; 81 (92%) of patients had complications postoperatively, and 25 (28%) died. Multiorgan failure (odds ratio = 3.4, P = .05) and hemorrhage (odds ratio = 6.1, P = .03) were the only independent predictors of mortality. During a median follow-up of 28.9 months, 39 (62%) of 63 surviving patients had one or more late complications: biliary stricture in 4 (6%), pseudocyst in 5 (8%), pancreatic fistula in 8 (13%), gastrointestinal fistula in 1 (2%), delayed collections in 3 (5%), and incisional hernia in 1 (2%); intervention was required in 10 (16%) patients. Sixteen (25%) of 63 surviving patients developed exocrine insufficiency, and 19 (33%) of 58 without prior diabetes mellitus developed endocrine insufficiency. CONCLUSIONS: Almost all patients undergoing necrosectomy developed significant early or late complications or both. Multiorgan failure and postoperative hemorrhage were independent predictors of mortality. Long-term follow-up was important because 62% developed complications, and 16% of those with complications required surgical or endoscopic intervention.PMID: 15855920