Invasive intervention timing for infected necrotizing pancreatitis: Late invasive intervention is not late for collection

Abstract

With the advance of invasive interventions, the treatment model for infected necrotizing pancreatitis (INP) has shifted from open surgery to the step-up minimally invasive treatment. Late intervention, originating from the open surgery era, has been questioned in the minimally invasive period. With the emergence of new high-quality evidence about the timing for intervention, it seems to be increasingly apparent that, even in the age of minimal invasiveness, “late intervention” waiting for the necrotic collections to be encapsulated is still necessary. This opinion review mainly discusses the intervention timing for INP.

Keywords: Pancreatitis; Walled-off necrosis; Minimally invasive surgery; Endoscopic drainage; Endoscopic gastric fenestration

Core Tip: Infected necrotizing pancreatitis is a potentially lethal disease that should be identified and managed early. For patients who can be stabilized with antibiotics and supportive care, the invasive treatment, either endoscopic or percutaneous approach, should be delayed for at least four weeks. While patients whose infection cannot be controlled by medication alone may need percutaneous drainage first in 48-72 h, followed by minimally invasive surgery (if necessary). Endoscopic gastric fenestration may be performed in selected patients. This innovative alternative intervention should also be postponed to more than four weeks, waiting for the necrosis to mature and the capsular lesions to fuse with the gastric wall.