ICU · GI/Nutrition

Acute pancreatitis: interventional management and complications

Also known as Pancreatic intervention · Endoscopic necrosectomy · Walled-off necrosis · Infected pancreatic necrosis step-up · PANTER trial · TENSION trial · Video-assisted retroperitoneal debridement · Lumen-apposing metal stent

Interventional management of severe acute pancreatitis is built on three pillars: (1) the STEP-UP approach for infected necrosis — drain first (percutaneous or endoscopic transluminal), add minimally invasive necrosectomy only if drainage fails, reserve open surgery for last resort; (2) TIMING — delay intervention ~4 weeks to allow demarcation and walling-off whenever possible (intervene earlier ONLY for clinical deterioration); (3) ROUTE — prefer endoscopic/percutaneous over open. PANTER trial (van Santvoort 2010, NEJM): step-up vs primary open necrosectomy — step-up superior (composite of major complications or death 40% vs 69%, RR 0.57; 35% treated with drainage alone). PANTER long-term follow-up (Hollemans 2019, mean 86 months): step-up had less exocrine and endocrine insufficiency, fewer incisional hernias, without increased risk of reinterventions. TENSION trial (van Brunschot 2018, Lancet): endoscopic step-up vs surgical step-up — no difference in the composite endpoint (43% vs 45%), but endoscopic had fewer fistulae and shorter hospital stay. PENGUIN trial (Bakker 2012, JAMA): endoscopic transluminal vs surgical necrosectomy — endoscopic fewer complications (20% vs 80%). Walled-off necrosis (over 4 wk, necrotic content) is NOT a pseudocyst (over 4 wk, fluid only) — management differs (WON needs necrosectomy/drainage, pseudocyst usually observed).