CC BY 4.0 · Surg J (N Y) 2022; 08(04): e322-e335
DOI: 10.1055/s-0042-1758229
Review Article

Evidence-Based Approach to the Surgical Management of Acute Pancreatitis

1   Nuffield Department of Surgical Sciences, Oxford University, Oxford, United Kingdom
Majid Khan
2   Acute Care Common Stem, Whipps Cross Hospital, London, United Kingdom
Niteen Tapuria*
3   Department of General Surgery, Milton Keynes University Hospital, Milton Keynes, United Kingdom
› Author Affiliations
Funding No source of funding to declare.


Background Acute pancreatitis is a significant challenge to health services. Remarkable progress has been made in the last decade in optimizing its management.

Methods This review is a comprehensive assessment of 7 guidelines employed in current clinical practice with an appraisal of the underlying evidence, including 15 meta-analyses/systematic reviews, 16 randomized controlled trials, and 31 cohort studies.

Results Key tenets of early management of acute pancreatitis include severity stratification based on the degree of organ failure and early goal-directed fluid resuscitation. Rigorous determination of etiology reduces the risk of recurrence. Early enteral nutrition and consideration of epidural analgesia have been pioneered in recent years with promising results. Indications for invasive intervention are becoming increasingly refined. The definitive indications for endoscopic retrograde cholangiopancreatography in acute pancreatitis are associated with cholangitis and common bile duct obstruction. The role of open surgical necrosectomy has diminished with the development of a minimally invasive step-up necrosectomy protocol. Increasing use of endoscopic ultrasound–guided intervention in the management of pancreatic necrosis has helped reduce pancreatic fistula rates and hospital stay.

Conclusion The optimal approach to surgical management of complicated pancreatitis depends on patient physiology and disease anatomy, in addition to the available resources and expertise. This is best achieved with a multidisciplinary approach. This review provides a distillation of the recommendations of clinical guidelines and critical discussion of the evidence that informs them and presents an algorithmic approach to key areas of patient management.

* Co-first authors

Supplementary Material

Publication History

Received: 28 February 2021

Accepted: 13 September 2022

Article published online:
22 November 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA