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World J Gastroenterol. Oct 14, 2014; 20(38): 13879-13892
Published online Oct 14, 2014. doi: 10.3748/wjg.v20.i38.13879
Treatment of severe acute pancreatitis and its complications
Enver Zerem
Enver Zerem, Department of Gastroenterology, University Clinical Center Tuzla, 75000 Tuzla, Bosnia and Herzegovina
Enver Zerem, Department of Medical Sciences, The Academy of Sciences and Arts of Bosnia and Herzegovina, 71000 Sarajevo, Bosnia and Herzegovina
Author contributions: Zerem E was the sole contributor to this paper.
Correspondence to: Enver Zerem, MD, PhD, Department of Gastroenterology, University Clinical Center Tuzla, Tuzla, Trnovac bb, 75000 Tuzla, Bosnia and Herzegovina.
Telephone: +387-35303300 Fax: +387-35266485
Received: February 14, 2014
Revised: April 8, 2014
Accepted: June 2, 2014
Published online: October 14, 2014

Severe acute pancreatitis (SAP), which is the most serious type of this disorder, is associated with high morbidity and mortality. SAP runs a biphasic course. During the first 1-2 wk, a pro-inflammatory response results in systemic inflammatory response syndrome (SIRS). If the SIRS is severe, it can lead to early multisystem organ failure (MOF). After the first 1-2 wk, a transition from a pro-inflammatory response to an anti-inflammatory response occurs; during this transition, the patient is at risk for intestinal flora translocation and the development of secondary infection of the necrotic tissue, which can result in sepsis and late MOF. Many recommendations have been made regarding SAP management and its complications. However, despite the reduction in overall mortality in the last decade, SAP is still associated with high mortality. In the majority of cases, sterile necrosis should be managed conservatively, whereas in infected necrotizing pancreatitis, the infected non-vital solid tissue should be removed to control the sepsis. Intervention should be delayed for as long as possible to allow better demarcation and liquefaction of the necrosis. Currently, the step-up approach (delay, drain, and debride) may be considered as the reference standard intervention for this disorder.

Keywords: Acute necrotizing pancreatitis, Infection, Sepsis, Drainage, Gastrointestinal endoscopy

Core tip: This review reports on the natural clinical course, diagnostic possibilities and treatment modalities in severe acute pancreatitis (SAP). The management of SAP varies with the severity and depends on the type of complication that requires treatment. Although no universally accepted treatment algorithm exists, the step-up approach using close monitoring, percutaneous or endoscopic drainage, followed by minimally invasive video-assisted retroperitoneal debridement has demonstrated to produce superior outcomes to traditional open necrosectomy and may be considered as the reference standard intervention for this disorder.