Surgical management of acute pancreatitis: Historical perspectives, challenges, and current management approaches

Table 1 Acute pancreatitis diagnosis, classification, and indications for surgery

	Criteria
Diagnosis of AP (any two)	Abdominal pain
	Serum lipase or amylase anomalies
	Characteristic radiological features
Mild AP1	No OF
	Absence of local or systemic complications
Moderately severe AP1	Transient OF (resolves in < 48 h)
	Local or systemic complications without persistent OF
Severe AP1	Persistent OF
Key indications for surgery	Infected necrosis
	Complications of pancreatitis
	Fistulas
	Pseudocyst
	Recurrent AP
	Abdominal compartment syndrome
	Systemic inflammatory response syndrome
	Acute necrotizing cholecystitis or intestinal ischemia
	Acute bleeding due to a failed endovascular approach

¹Revised Atlanta Classification.

AP: Acute pancreatitis; OF: Organ failure.

Table 2 Summary of key surgical recommendations in different guidelines for acute pancreatitis management

IAP1 (grade A and B)[31]	WSES2 (grade 1A, 1B, or 1C)[4]	AGA (pancreatic necrosis)[33]
Mild AP is not an indication for pancreatic surgery (grade B recommendation)	Routine ERCP is not indicated (1A)	Drainage and/or debridement of pancreatic necrosis is indicated in patients with IPN
IPN in patients with clinical signs and symptoms of sepsis is an indication for intervention (recommendation grade B)	ERCP is indicated in patients with GSAP and cholangitis (1B)	Pancreatic debridement should be avoided in the early, acute period (first two weeks)
Early surgery is not recommended within 14 d after the onset of the disease in patients with necrotic pancreatitis (recommendation grade B)	Clinical deterioration with signs of INP is an indication of intervention (1C)	Percutaneous and transmural ED are both appropriate first-line nonsurgical approaches to the management of patients with WON
Interventional management should favor an organ-preserving approach (grade B recommendation)	As a continuum in a step-up approach after percutaneous/endoscopic procedure (1C)	Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early acute period (< 2 wk)
ES is an alternative to cholecystectomy in those who are not fit to undergo surgery (grade B recommendation)	In IPN, percutaneous drainage as the first-line of treatment (1A)	SEMS in the form of LAMS appears superior to plastic stents for endoscopic transmural drainage of necrosis
	Minimally invasive surgical strategies result in fewer postoperative new-onset OF (1B)	The use of DEN should be reserved for those patients with limited necrosis and not responding to endoscopic transmural drainage
	Laparoscopic cholecystectomy is recommended during index admission in mild GSAP (1A)	Minimally invasive operative approaches to the debridement of IPN are preferred to open approaches
	The risk of recurrent pancreatitis is reduced when ERCP and sphincterotomy are performed during index admission (1B)
	Over-resuscitation of patients with early SAP should be avoided; intra-abdominal pressure monitoring is necessary (1C)	A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage, followed by DEN, and then surgical debridement is reasonable
	OA should be avoided if other strategies can be used to manage IAH (1C)
	Not to use OA after necrosectomy (1C)
	Not to debride or perform an early necrosectomy if forced to perform an early OA due to ACS (1A)
		For patients with disconnected left pancreatic remnants after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy can be performed

¹Grade A: Strong evidence that requires a meta-analysis of randomized controlled trials or at least one randomized controlled trial (evidence categories Ia and Ib); Grade B: Intermediate evidence, requires nonrandomized clinical studies (evidence categories IIa, IIb, and III).

²Grading of recommendations assessment 1A: Strong recommendation, high-quality evidence; 1B: Strong recommendation, moderate-quality evidence; 1C: Strong recommendation, low-quality or very low-quality evidence.

ACS: Abdominal compartment syndrome; AP: Acute pancreatitis; DEN: Direct endoscopic necrosectomy; ES: Endoscopic sphincterotomy; LAMS: Lumen-apposing metal stents; OA: Open abdomen; SAP: Severe acute pancreatitis; SEMS: Self-expanding metal stents; VARD: Video-assisted retroperitoneal debridement; WON: Walled-off necrosis; ERCP: Endoscopic retrograde cholangiopancreatography; IPN: Infected pancreatic necrosis; IAP: International Association of Pancreatology; WSES: World Society of Emergency Surgery; AGA: American Gastroenterological Association; GSAP: Gallstone-associated acute pancreatitis; INP: Infected necrotizing pancreatitis; ED: Endoscopic drainage.