Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 21, 2022; 28(27): 3383-3397
Published online Jul 21, 2022. doi: 10.3748/wjg.v28.i27.3383
Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes
Birte Purschke, Louisa Bolm, Max Nikolaus Meyer, Hiroki Sato
Birte Purschke, Louisa Bolm, Department of Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA 02114, United States
Max Nikolaus Meyer, Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, United States
Hiroki Sato, Department of Medicine, Asahikawa Medical University, Asahikawa 0788510, Hokkaido, Japan
Hiroki Sato, Department of Gastroenterology, Asahikawa Kosei Hospital, Asahikawa 0788211, Hokkaido, Japan
Author contributions: Purschke B wrote and edited the manuscript, and collected the clinical data and evidence; Bolm L edited the manuscript and reviewed the discussion about interventional surgical strategies; Meyer MN reviewed the manuscript and provided recommendations on treatment strategies; Sato H reviewed the manuscript and provided strategies and recommendations on the endoscopic intervention part; all authors have read and approved the final manuscript.
Supported by Japan Society for the Promotion of Science KAKENHI, No. 19K17480 and No. 21KK0283 (to Sato H).
Conflict-of-interest statement: Authors declare no conflicts of interests for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Hiroki Sato, MD, PhD, Academic Fellow, Chief Doctor, Research Fellow, Department of Medicine, Asahikawa Medical University, 1-1, Midorigaoka Higashi 2 Jyo 1 Chome, Asahikawa 0788510, Hokkaido, Japan.
Received: January 20, 2022
Peer-review started: January 20, 2022
First decision: February 24, 2022
Revised: March 7, 2022
Accepted: June 15, 2022
Article in press: June 15, 2022
Published online: July 21, 2022

Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.

Keywords: Pancreatitis, Acute necrotizing pancreatitis, Necrosis, Superinfection, Endoscopy, Surgery

Core Tip: Acute pancreatitis remains a potentially life-threatening disease. Necrotizing pancreatitis (NP) is associated with superinfection and increases the mortality rate. We summarized the current evidence and clinical recommendations of multidisciplinary approaches focusing on conservative, interventional, and surgical treatment. The interventional approach is often required as a first step in treating infected NP, while further options include minimal invasive or an escalation to open surgical treatment. Although this “step-up approach” is well-established, the exact timing, sequence, and procedure choice remain controversial; this review aims to summarize current evidence and to provide guidance for decision making in clinical practice.