The management of acute necrotizing pancreatitis (ANP) has undergone a change of paradigms during the last 2 decades with a decreasing impact of surgical interventions. Modern ANP management is done conservatively as long as possible and therapeutic approaches aim at volume resuscitation, pain management and early enteral nutrition. The diagnostic gold standard of contrast-enhanced CT scan helps to evaluate the extent of necrosis of the pancreas, which correlates with the risk of tissue infection. The crucial point for decision making is the proven existence of infected pancreatic necrosis. This can be achieved by diagnostic needle aspiration of the necrotic material and staining to prove bacterial and/or fungal infection. In case of infected necrosis - besides calculated antimicrobial treatment - an interventional or surgical approach is required to prevent systemic septic progression of the disease. As the first step, percutaneous interventional drainage and spilling of the necrosis are preferable. In case of insufficient clearing of the infectious focus, a step-up approach must be considered, which implies a retroperitoneoscopic or transabdominal minimally invasive necrosectomy and drain placement. Postoperatively, a continuous lavage should be performed using these drains. In case of further deterioration of the patient or development of associated intra-abdominal complications (e.g. bowel perforation or uncontrolled bleeding), an open surgical intervention must always be regarded as a salvage therapy and this offers the possibility to control complications and perform a further necrosectomy and extensive lavage for focus control. However, associated morbidity (e.g. pancreatic fistula, fluid collections, pseudocysts) is about 50-60% and mortality up to 20%. In summary, ANP is managed primarily by a conservative therapy. In case of infected necrosis, interventional and minimally invasive approaches are the therapy of choice. Open surgery should be considered for patients deteriorating despite other measures and should be postponed as long as possible.

1.
Büchler MW, Gloor B, Müller CA, Friess H, Seiler CA, Uhl W: Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 2000;232:619-626.
2.
Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al; Pancreatitis Classification Working Group: Classification of acute pancreatitis - 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-111.
3.
Hackert T, Tjaden C, Büchler MW: [Developments in pancreatic surgery during the past ten years]. Zentralbl Chir 2014;139:292-300.
4.
Werner J, Hartwig W, Hackert T, Büchler MW: Surgery in the treatment of acute pancreatitis - open pancreatic necrosectomy. Scand J Surg 2005;94:130-134.
5.
Cho JH, Kim TN, Chung HH, Kim KH: Comparison of scoring systems in predicting the severity of acute pancreatitis. World J Gastroenterol 2015;21:2387-2394.
6.
Acevedo-Piedra NG, Moya-Hoyo N, Rey-Riveiro M, Gil S, Sempere L, Martínez J, Lluís F, Sánchez-Payá J, de-Madaria E: Validation of the determinant-based classification and revision of the Atlanta classification systems for acute pancreatitis. Clin Gastroenterol Hepatol 2014;12:311-316.
7.
Dellinger EP, Forsmark CE, Layer P, Lévy P, Maraví-Poma E, Petrov MS, Shimosegawa T, Siriwardena AK, Uomo G, Whitcomb DC, Windsor JA; Pancreatitis Across Nations Clinical Research and Education Alliance (PANCREA): Determinant-based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg 2012;256:875-880.
8.
Meher S, Mishra TS, Sasmal PK, Rath S, Sharma R, Rout B, Sahu MK: Role of biomarkers in diagnosis and prognostic evaluation of acute pancreatitis. J Biomark 2015;2015:519534.
9.
James PD, Kaplan GG, Myers RP, Hubbard J, Shaheen AA, Tinmouth J, Yong E, Love J, Heitman SJ: Decreasing mortality from acute biliary diseases that require endoscopic retrograde cholangiopancreatography: a nationwide cohort study. Clin Gastroenterol Hepatol 2014;12:1151-1159.
10.
Leese T, Neoptolemos JP, Baker AR, Carr-Locke DL: Management of acute cholangitis and the impact of endoscopic sphincterotomy. Br J Surg 1986;73:988-992.
11.
Tse F, Yuan Y: Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012;5:CD009779.
12.
van Santvoort HC, Besselink MG, de Vries AC, et al: Early endoscopic retrograde cholangiopancreatography in predicted severe acute biliary pancreatitis: a prospective multicenter study. Ann Surg 2009;250:68-75.
13.
Morris S, Gurusamy KS, Patel N, Davidson BR: Cost-effectiveness of early laparoscopic cholecystectomy for mild acute gallstone pancreatitis. Br J Surg 2014;101:828-835.
14.
Gurusamy KS, Nagendran M, Davidson BR: Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Cochrane Database Syst Rev 2013;9:CD010326.
15.
Fritz S, Hackert T, Hartwig W, Rossmanith F, Strobel O, Schneider L, et al: Bacterial translocation and infected pancreatic necrosis in acute necrotizing pancreatitis derives from small bowel rather than from colon. Am J Surg 2010;200:111-117.
16.
Kumar A, Singh N, Prakash S, Saraya A, Joshi YK: Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes. J Clin Gastroenterol 2006;40:431-434.
17.
Petrov MS, Loveday BP, Pylypchuk RD, McIlroy K, Phillips AR, Windsor JA: Systematic review and meta-analysis of enteral nutrition formulations in acute pancreatitis. Br J Surg 2009;96:1243-1252.
18.
Bakker OJ, van Brunschot S, van Santvoort HC, et al: Early versus on-demand nasoenteric tube feeding in acute pancreatitis. N Engl J Med 2014;371:1983-1993.
19.
Eatock FC, Chong P, Menezes N, Murray L, McKay CJ, Carter CR, et al: A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol 2005;100:432-439.
20.
Isenmann R, Rünzi M, Kron M, Kahl S, Kraus D, Jung N, et al; German Antibiotics in Severe Acute Pancreatitis Study Group: Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial. Gastroenterology 2004;126:997-1004.
21.
Jiang K, Huang W, Yang XN, Xia Q: Present and future of prophylactic antibiotics for severe acute pancreatitis. World J Gastroenterol 2012;18:279-284.
22.
Dellinger EP, Tellado JM, Soto NE, Ashley SW, Barie PS, Dugernier T, et al: Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study. Ann Surg 2007;245:674-683.
23.
Garcia-Barrasa A, Borobia FG, Pallares R, Jorba R, Poves I, Busquets J, et al: A double-blind, placebo-controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis. J Gastrointest Surg 2009;13:768-774.
24.
Wittau M, Mayer B, Scheele J, Henne-Bruns D, Dellinger EP, Isenmann R: Systematic review and meta-analysis of antibiotic prophylaxis in severe acute pancreatitis. Scand J Gastroenterol 2011;46:261-270.
25.
Mortelé KJ, Girshman J, Szejnfeld D, Ashley SW, Erturk SM, Banks PA, Silverman SG: CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J Roentgenol 2009;192:110-116.
26.
Freeny PC, Hauptmann E, Althaus SJ, Traverso LW, Sinanan M: Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results. AJR Am J Roentgenol 1998;170:969-975.
27.
Bruennler T, Langgartner J, Lang S, Zorger N, Herold T, Salzberger B, Feuerbach S, Schoelmerich J, Hamer OW: Percutaneous necrosectomy in patients with acute, necrotizing pancreatitis. Eur Radiol 2008;18:1604-1610.
28.
Escourrou J, Shehab H, Buscail L, et al: Peroral transgastric/transduodenal necrosectomy: success in the treatment of infected pancreatic necrosis. Ann Surg 2008;248:1074-1080.
29.
Seewald S, Ang TL, Teng KC, Soehendra N: EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis. Dig Endosc 2009;21(suppl 1):S61-S65.
30.
van Brunschot S, van Grinsven J, Voermans RP, et al: Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol 2013;13:161.
31.
Fernández-Cruz L, Cesar-Borges G, López-Boado MA, Orduña D, Navarro S: Minimally invasive surgery of the pancreas in progress. Langenbecks Arch Surg 2005;390:342-354.
32.
Bradley EL 3rd: Operative management of acute pancreatitis: ventral open packing. Hepatogastroenterology 1991;38:134-138.
33.
Sarr MG, Nagorney DM, Mucha P Jr, et al: Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains. Br J Surg 1991;78:576-581.
34.
Beger HG, Buchler M, Bittner R, et al: Necrosectomy and postoperative local lavage in necrotizing pancreatitis. Br J Surg 1988;75:207-212.
35.
Fernandez-del Castillo C, Rattner DW, Makary MA, et al: Debridement and closed packing for the treatment of necrotizing pancreatitis. Ann Surg 1998;228:676-684.
36.
van Santvoort HC, Besselink MG, Bakker OJ, et al: A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362:1491-1502.
37.
Reddy M, Jindal R, Gupta R, Yadav TD, Wig JD: Outcome after pancreatic necrosectomy: trends over 12 years at an Indian centre. ANZ J Surg 2006;76:704-709.
38.
Connor S, Alexakis N, Raraty MG, et al: Early and late complications after pancreatic necrosectomy. Surgery 2005;137:499-505.
39.
Nelsen EM, Johnson EA, Walker AJ, Pfau P, Gopal DV: Endoscopic ultrasound-guided pancreatic pseudocyst cystogastrostomy using a novel self-expandable metal stent with antimigration system: a case series. Endosc Ultrasound 2015;4:229-234.
40.
Lerch MM, Stier A, Wahnschaffe U, Mayerle J: Pancreatic pseudocysts: observation, endoscopic drainage, or resection? Dtsch Arztebl Int 2009;106:614-621.
41.
Papachristou GI, Gleeson FC, Petersen BT, Levy MJ: Pancreatic endoscopic ultrasound-assisted rendezvous procedure to facilitate drainage of nondilated pancreatic ducts. Endoscopy 2007;39(suppl 1):E324-E325.
42.
Voermans RP, Veldkamp MC, Rauws EA, Bruno MJ, Fockens P: Endoscopic transmural debridement of symptomatic organized pancreatic necrosis (with videos). Gastrointest Endosc 2007;66:909-916.
43.
Hocke M, Will U, Gottschalk P, Settmacher U, Stallmach A: Transgastral retroperitoneal endoscopy in septic patients with pancreatic necrosis or infected pancreatic pseudocysts. Z Gastroenterol 2008;46:1363-1368.
44.
Seifert H, Biermer M, Schmitt W, Jürgensen C, Will U, Gerlach R, Kreitmair C, Meining A, Wehrmann T, Rösch T: Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009;58:1260-1266.
45.
Gardner TB, Coelho-Prabhu N, Gordon SR, Gelrud A, Maple JT, Papachristou GI, Freeman ML, Topazian MD, Attam R, Mackenzie TA, Baron TH: Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 2011;73:718-726.
46.
Baril NB, Ralls PW, Wren SM, Selby RR, Radin R, Parekh D, Jabbour N, Stain SC: Does an infected peripancreatic fluid collection or abscess mandate operation? Ann Surg 2000;231:361-367.
47.
Oláh A, Belágyi T, Bartek P, Pohárnok L, Romics L Jr: Alternative treatment modalities of infected pancreatic necrosis. Hepatogastroenterology 2006;53:603-607.
48.
Navalho M, Pires F, Duarte A, Gonçalves A, Alexandrino P, Távora I: Percutaneous drainage of infected pancreatic fluid collections in critically ill patients: correlation with C-reactive protein values. Clin Imaging 2006;30:114-119.
49.
Szentkereszty Z, Kotán R, Pósán J, Arkossy P, Sápy P: Therapeutic tactics in the treatment of acute necrotizing pancreatitis. Hepatogastroenterology 2008;55:266-269.
50.
Mortelé KJ, Girshman J, Szejnfeld D, Ashley SW, Erturk SM, Banks PA, Silverman SG: CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J Roentgenol 2009;192:110-116.
51.
Rocha FG, Benoit E, Zinner MJ, Whang EE, Banks PA, Ashley SW, Mortele KJ: Impact of radiologic intervention on mortality in necrotizing pancreatitis: the role of organ failure. Arch Surg 2009;144:261-265.
52.
Cuschieri A: Pancreatic necrosis: pathogenesis and endoscopic management. Semin Laparosc Surg 2002;9:54-63.
53.
Zhou ZG, Zheng YC, Shu Y, Hu WM, Tian BL, Li QS, Zhang ZD: Laparoscopic management of severe acute pancreatitis. Pancreas 2003;27:e46-e50.
54.
Parekh D: Laparoscopic-assisted pancreatic necrosectomy: a new surgical option for treatment of severe necrotizing pancreatitis. Arch Surg 2006;141:895-902.
55.
Gambiez LP, Denimal FA, Porte HL, Saudemont A, Chambon JP, Quandalle PA: Retroperitoneal approach and endoscopic management of peripancreatic necrosis collections. Arch Surg 1998;133:66-72.
56.
Castellanos G, Piñero A, Serrano A, Parrilla P: Infected pancreatic necrosis: translumbar approach and management with retroperitoneoscopy. Arch Surg 2002;137:1060-1063.
57.
Raraty MG, Halloran CM, Dodd S, Ghaneh P, Connor S, Evans J, Sutton R, Neoptolemos JP: Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 2010;251:787-793.
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