Surgery for Necrotizing Pancreatitis

Over the last few decades, there has been a radical shift in the management of patients with necrotizing pancreatitis, with a reversal in approach from early aggressive surgical intervention to delayed minimal access approaches. Radiologically-guided percutaneous catheter drainage or endoscopic transluminal drainage are now considered first line treatments as part of a “step-up” approach. When there is lack of clinical improvement, minimal access surgical or endoscopic necrosectomy are considered as the next “step-up” procedures prior to open necrosectomy. The best choice of step-up approach appears to be endoscopic because of lower rates of pancreatic fistula and shorter length of hospital stay. However, all techniques should be available in a pancreatic center's armamentarium against this complex disease. This includes open necrosectomy, which remains an essential part of treatment algorithms for those patients failing to improve with minimal access techniques. In the future, an individualized approach, based on patient and disease characteristics, the location of collections and the degree of encapsulation will become the new standard.