Management of acute pancreatitis:: From surgery to interventional intensive care

In recent years, treatment of severe acute pancreatitis has shifted away from early surgical treatment to aggressive intensive care. While the treatment is conservative in the early phase, surgery might be considered in the later phase of the disease. Surgical debridement is still the gold standard'' for treatment of infected pancreatic and peripancreatic necrosis. Advances in radiological imaging, new developments in interventional radiology, and other minimal access interventions have revolutionised the management of many surgical conditions over the past decades. Several interventional therapy regimens, including endoscopic retrograde cholangiopancreatography ( ERCP) and sphincterotomy, fine needle aspiration for bacteriology (FNAB), percutaneous or endoscopic drainage of peripancreatic fluid collections, pseudocysts, and late abscesses, as well as selective angiography and catheter directed embolisation of acute pancreatitis associated bleeding complications have been well established as diagnostic and therapeutic standards in the management of acute pancreatitis. Secondary to recent technical improvements in interventional therapy and minimally invasive surgery, even infected pancreatic necrosis has successfully been treated in selected patients. However, technical feasibility does not obviate sound clinical judgement. We must be cautious in the application of new technologies in the absence of well designed clinical trials. Thus minimally invasive surgery and interventional therapy for infected necrosis should be limited to clinical trials and specific indications in patients who are critically ill and otherwise unfit for conventional surgery.