Surgical Treatment of Necrotizing Pancreatitis

Necrotizing pancreatitis is associated with significant morbidity and mortality, particularly in cases with infected necrosis. The management of these complex patients has radically shifted in the past 2 decades with major advances in the percutaneous, endoscopic and minimally invasive surgical techniques employed in the care of these patients. The step-up approach, incorporating percutaneous drainage and endoscopic transgastric necrosectomy, reserving surgical debridement for a small subset of patients, has significantly improved clinical outcomes. Delayed and minimally invasive approaches are now preferred to traditional open necrosectomy, with laparoscopic transgastric necrosectomy as an option. Transgastric necrosectomy has been established as a first-line treatment for debridement. Video-assisted retroperitoneal debridement (VARD) and sinus tract endoscopy (STE) are the most useful surgical approaches and are invaluable in cases where percutaneous drainage or endoscopic transluminal necrosectomy prove inadequate or incomplete. Open necrosectomy is reserved for rare cases with refractory infection, anatomical constraints, concurrent intra-abdominal pathology and lack of familiarity with minimally invasive approaches, but timely transfer to a regional center of excellence is encouraged. This review summarizes the evolution of contemporary surgical techniques, highlights the best evidence and delineates the role of each technique in a multidisciplinary framework.