ACUTE PANCREATITIS: CURRENT SURGICAL TREATMENT STRATEGIES

Abstract

Acute pancreatitis (AP) is a sudden inflammation of the pancreas, where approximately 20-25% of cases progress to severe or necrotizing forms, associated with high mortality rates. The management of these severe forms has undergone a radical transformation in recent decades. This narrative review highlights the paradigm shift, abandoning early and aggressive open surgery in favor of a "step-up," minimally invasive, and, crucially, delayed approach. The fundamental principle is to delay intervention for at least 4 weeks to allow for the demarcation of necrosis ("walled-off necrosis" - WON). The current strategy prioritizes drainage as the first step, preferably transluminal endoscopic drainage (EUS-guided) with the use of luminal apposition stents (LAMS), or, alternatively, percutaneous drainage. If drainage alone fails, the next step is direct endoscopic necrosectomy (DEN). Minimally invasive surgical necrosectomy (VARD/MARPN) is considered if endoscopy fails, while traditional open necrosectomy is now a last resort, reserved for failures or serious complications (such as massive bleeding or compartment syndrome). The management of biliary pancreatitis is also stratified, indicating early cholecystectomy in mild cases and delayed cholecystectomy in severe cases.