Acute pancreatitis surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Monish Thuvooru Muthu Kalyanaraman, M.B.B.S[2]
Surgery / Procedural Therapy
This microchapter covers procedural and surgical interventions for acute pancreatitis, including cholecystectomy for biliary pancreatitis, the step-up approach for necrotizing pancreatitis, endoscopic and surgical necrosectomy techniques, lumen-apposing metal stents, and management of disconnected pancreatic duct syndrome. Medical therapy (fluid resuscitation, analgesia, nutrition, antibiotics, ERCP for cholangitis) is addressed in the medical therapy microchapter.
Cholecystectomy for Biliary Pancreatitis
Mild Gallstone Pancreatitis
Same-admission cholecystectomy (preferably before discharge) is recommended to prevent recurrent gallstone-related complications (ACG 2024: key concept).[1]
The PONCHO trial (Lancet 2015; n=266) — a multicenter RCT from 23 Dutch centers — demonstrated that same-admission cholecystectomy reduced readmission for gallstone-related complications or mortality compared with interval cholecystectomy (5% vs 17%; RR 0.28; 95% CI 0.12–0.66; P=0.002), with a very low rate of cholecystectomy-related complications in both groups.[2]
Without cholecystectomy, 18% of patients are readmitted for recurrent biliary events, including 8% with recurrent pancreatitis.[2]
A 2026 Swedish nationwide cohort study (n=9,593) confirmed that same-admission cholecystectomy was associated with the lowest recurrence of acute pancreatitis (3.4%) and other gallstone-related complications (1.6%), compared with ERCP only (4.9% recurrence; 19.9% other complications) and no intervention (17.5% recurrence; 16.3% other complications).[3]
Biliary sphincterotomy alone does not reliably prevent all gallstone-related complications and should be reserved for patients who are not surgical candidates.[1]
Despite strong evidence, fewer than half of patients with mild gallstone pancreatitis undergo cholecystectomy during the index admission in practice.[4]
Moderately Severe or Severe Gallstone Pancreatitis
Cholecystectomy should be deferred until active inflammation subsides and peripancreatic fluid collections resolve or stabilize (ACG 2024: key concept). In patients with necrotizing biliary pancreatitis, cholecystectomy is typically delayed and may be incorporated into the management of pancreatic necrosis or performed electively after discharge, ideally within 8–10 weeks.[1][5]
Management of Necrotizing Pancreatitis
Approximately 10–20% of patients with acute pancreatitis develop necrosis. Of these, approximately one-third develop infected necrosis, which frequently requires invasive intervention.[1][6]
Indications for Intervention
| Indication | Timing / Notes |
|---|---|
| Infected pancreatic necrosis not responding to antibiotics | Most common indication; clinical + radiographic diagnosis preferred over routine FNA |
| Symptomatic sterile necrosis (pain, gastric outlet or biliary obstruction, failure to thrive) | ≥4–8 weeks after onset; collections should be well-organized (WON) |
| Disconnected pancreatic duct syndrome with persistent/recurrent collections | After maturation of collections |
| Asymptomatic pseudocyst or necrosis (any size) | No intervention indicated (ACG 2024 key concept) |
Diagnosis of Infected Necrosis
Infected necrosis should be suspected in patients who deteriorate or fail to improve after 7–10 days, with persistent fevers, rising inflammatory markers, or gas within a necrotic collection on CT. Routine fine-needle aspiration (FNA) is no longer recommended as the primary diagnostic method due to a 25% false-negative rate; clinical and radiographic criteria are generally sufficient to guide management.[7]
Timing of Intervention
Intervention should be delayed preferably ≥4 weeks in stable patients to allow liquefaction of necrotic contents and development of a fibrous wall (walled-off necrosis), making removal safer and more effective (ACG 2024: key concept). The AGA 2020 update similarly recommends waiting at least 4 weeks for intervention on any type of necrosis when the patient is stable.[1][6]
The POINTER trial (NEJM 2021; n=104) compared immediate catheter drainage (within 24 hours of diagnosis) versus postponed drainage (awaiting walled-off necrosis). Immediate drainage was not superior (mean CCI score 57 vs 58; P=0.90). Patients in the postponed group required fewer interventions (mean 2.6 vs 4.4). Mortality was 13% in the immediate-drainage group and 10% in the postponed-drainage group (RR 1.25; 95% CI 0.42–3.68; not significant). Crucially, 39% of patients in the postponed group were managed with antibiotics alone and avoided drainage entirely; 17 of these 19 patients survived.[8]
In patients with rapid clinical deterioration (progressive organ failure, sepsis), earlier intervention can be considered at centers with appropriate expertise.[1]
Step-Up Approach
The minimally invasive step-up approach is the current standard of care for infected necrotizing pancreatitis, replacing primary open necrosectomy (ACG 2024: key concept — minimally invasive methods preferred).[1]
Surgical Step-Up vs Open Necrosectomy: PANTER Trial
The PANTER trial (NEJM 2010; n=88) — the first RCT comparing the surgical step-up approach (percutaneous catheter drainage → video-assisted retroperitoneal debridement [VARD] if needed) with primary open necrosectomy — demonstrated that the step-up approach reduced the composite endpoint of major complications and death (40% vs 69%; RR 0.57). Thirty-five percent of patients in the step-up group were successfully treated with catheter drainage alone.[9]
Long-term follow-up (Hollemans et al., Gastroenterology 2019; mean 86 months) confirmed the superiority of the step-up approach (44% vs 73% death or major complications; P=0.005), with significantly fewer incisional hernias (23% vs 53%), less exocrine insufficiency (29% vs 56%), and less endocrine insufficiency (40% vs 64%), and no increased need for reinterventions.[10]
Endoscopic vs Surgical Step-Up: TENSION and MISER Trials
The TENSION trial (multicenter RCT; n=98) compared endoscopic vs surgical step-up approaches: no significant difference in mortality and major morbidity (43% vs 45%; P=0.88), but the endoscopic approach resulted in significantly fewer pancreaticocutaneous fistulas (5% vs 32%; P=0.001) and shorter hospital stay (53 vs 69 days; P=0.014).[11]
Long-term follow-up (ExTENSION, Gastroenterology 2022) confirmed fewer fistulas and reinterventions with the endoscopic approach.[12]
The MISER trial (single-center RCT; n=66) confirmed these findings: no mortality difference (endoscopy 8.8% vs surgery 6.3%; P=0.999), but the endoscopic approach resulted in fewer major complications (12% vs 41%) and no enteral or pancreaticocutaneous fistulae (0% vs 28%; P=0.001), with lower costs ($75,830 vs $117,492).[13]
| Outcome | Endoscopic / Step-Up | Surgical / Open Comparator | Key Trials |
|---|---|---|---|
| Major morbidity + mortality | 43% | 45% | TENSION (endoscopic vs surgical step-up) |
| Pancreaticocutaneous fistula | 5% | 32% | TENSION |
| Major complications | 12% | 41% | MISER |
| Fistula (enteral or pancreatic) | 0% | 28% | MISER |
| Long-term major complications / death (step-up vs open necrosectomy) | 44% (step-up) | 73% (open) | PANTER long-term |
The endoscopic step-up approach is now the preferred first-line strategy when the collection abuts the gastric or duodenal wall. Collections extending to the flanks or pelvis may require percutaneous catheter drainage as a first step or as an adjunct.[1]
The PENGUIN trial (JAMA 2012; n=20) — the first RCT comparing endoscopic transgastric necrosectomy with surgical necrosectomy — demonstrated a reduced proinflammatory response (lower IL-6) and less new-onset organ failure with the endoscopic approach, providing the initial signal that led to the larger TENSION and MISER trials.[14]
Percutaneous Catheter Drainage
Percutaneous drainage serves as the first step in the surgical step-up approach and can temporize critically ill patients with infected necrosis. In the PANTER trial, 35% of patients in the step-up group were managed with percutaneous catheter drainage alone without progression to necrosectomy.[9][10]
Percutaneous drainage is also indicated when necrotic collections are not endoscopically accessible (paracolic gutters, pelvis), or as a bridge to allow maturation of walled-off necrosis before definitive endoscopic or surgical intervention.[6]
Open Necrosectomy
Open necrosectomy is now reserved for cases where minimally invasive approaches fail or are not technically feasible. Options include necrosectomy with closed continuous lavage, or necrosectomy with planned staged reoperations. The PANTER trial demonstrated substantially higher morbidity with open surgery, particularly new-onset organ failure, incisional hernias, and pancreatic insufficiency.[9][10]
Endoscopic Techniques
EUS-Guided Transmural Drainage
Endoscopic ultrasound (EUS)-guided transmural drainage is the cornerstone of the endoscopic step-up approach. A transmural tract is created (typically transgastric) into the walled-off necrosis, followed by stent placement to maintain drainage.[6]
Lumen-Apposing Metal Stents (LAMS)
LAMS (15–20 mm diameter) provide a larger lumen compared with double-pigtail plastic stents (7–10 Fr), facilitating drainage of necrotic debris and enabling direct endoscopic necrosectomy (DEN) through the stent. A prospective multicenter trial (n=40) demonstrated 97.5% radiographic WON resolution by 60 days with protocolized LAMS and necrosectomy.[15]
A prospective comparison of LAMS versus double-pigtail plastic stents in infected necrotizing pancreatitis (n=104) found no difference in need for necrosectomy (64% vs 53%), mortality, major complications, or costs.[16] A 2025 meta-analysis of 8 RCTs (>500 patients) similarly found no difference in clinical success, adverse events, mortality, or need for necrosectomy between metal and plastic stents, though metal stents had shorter procedure duration.[17] LAMS should be removed after 3–4 weeks to minimize bleeding and buried-stent complications.
Placement of coaxial double-pigtail plastic stents through LAMS may reduce stent-related adverse events. For patients with disconnected pancreatic duct syndrome, transmural plastic stents should be left in situ indefinitely to maintain internal drainage.[6]
Current consensus recommends either LAMS or plastic stents, depending on institutional expertise and individual patient factors. Biflanged metal stents (BFMS) are an emerging alternative with promising reintervention-free success rates in recent trials.[1]
Direct Endoscopic Necrosectomy (DEN)
DEN involves introducing the endoscope through the transmural tract into the necrotic cavity and removing necrotic tissue under direct vision. Multiple sessions may be required.[6]
The WONDER-01 trial (Gastroenterology 2026; n=70) — a multicenter RCT — compared immediate DEN after EUS-guided drainage versus a drainage-oriented step-up approach. This trial enrolled patients with both infected and symptomatic sterile walled-off necrosis requiring EUS-guided intervention. Immediate DEN was associated with shorter time to clinical success (median 29 vs 44 days; P=0.009), with comparable adverse event rates (24% vs 22%). However, all patients in the immediate DEN arm required necrosectomy, compared with 46% in the step-up arm. Although not statistically significant (P=0.41), mortality was numerically higher in the immediate DEN arm (12% vs 5.4%); this finding warrants monitoring in future trials.[18]
A separate RCT (Mohamadnejad et al., Clin Gastroenterol Hepatol 2026; n=50) found that 44% of patients in the on-demand group resolved WON without necrosectomy, with similar clinical success rates (92% vs 88%). Moderate-to-severe adverse events were numerically lower with the on-demand approach (0% vs 16%), though this did not reach statistical significance (P=0.1).[19]
The optimal timing of DEN remains an area of active investigation. A 2026 meta-analysis of 5 RCTs (269 patients) found immediate DEN was associated with higher clinical success (OR 2.56; 95% CI 1.03–6.37) and shorter hospital stay (MD −8 days), with no difference in adverse events.[20]
Disconnected Pancreatic Duct Syndrome
Disconnected pancreatic duct syndrome (DPDS) occurs when necrosis disrupts the main pancreatic duct, resulting in a viable distal pancreatic segment disconnected from the gastrointestinal tract. This occurs in approximately 20–40% of patients with necrotizing pancreatitis. DPDS can cause persistent pancreatic fistula, recurrent fluid collections, or recurrent pancreatitis of the disconnected tail segment.[21]
Evaluation: Secretin-enhanced MRCP or ERCP can define ductal anatomy.[21]
| Management Option | Key Features |
|---|---|
| Endoscopic transmural drainage + indefinite plastic stents | Least invasive; preferred for non-surgical candidates; maintains internal drainage |
| Surgical internal drainage (Roux or gastric anastomosis) | Preserves pancreatic tissue; not always technically feasible |
| Distal pancreatectomy (± splenectomy) | Definitive; higher blood loss and morbidity; islet autotransplantation may preserve endocrine function |
Vascular Complications
Vascular complications (pseudoaneurysm, splenic or portal vein thrombosis, hemorrhage into collections) occur in up to 10% of necrotizing pancreatitis cases and carry high mortality if untreated. Pseudoaneurysm rupture is a surgical emergency; angiographic embolization is the first-line treatment.[1][6]
Referral to Centers of Expertise
Patients with necrotizing pancreatitis requiring intervention should be referred to high-volume centers with multidisciplinary expertise (gastroenterology, interventional radiology, surgery) — this is repeatedly emphasized in current guidelines and is associated with reduced morbidity and mortality.[1][6]
Clinically Actionable Recommendations
- Perform same-admission cholecystectomy (preferably before discharge) for mild gallstone pancreatitis; defer cholecystectomy in severe/necrotizing disease until collections resolve.[1][2]
- Do not intervene on asymptomatic pseudocysts or necrosis regardless of size.[1]
- Use a step-up approach for infected necrotizing pancreatitis, preferring endoscopic over surgical when the collection abuts the GI tract.[1][9][11][13]
- Delay intervention ≥4 weeks in stable patients to allow walled-off necrosis to develop; antibiotics alone can avert the need for drainage in >1/3 of patients.[8]
- Remove LAMS after 3–4 weeks; leave transmural plastic stents in situ indefinitely for DPDS.[6]
- Refer necrotizing pancreatitis patients to high-volume multidisciplinary centers.[1]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 Tenner S, Vege SS, Sheth SG; et al. (2024). "American College of Gastroenterology Guidelines: Management of Acute Pancreatitis". Am J Gastroenterol. 119 (3): 419–437. doi:10.14309/ajg.0000000000002645.
- ↑ 2.0 2.1 2.2 da Costa DW, Bouwense SA, Schepers NJ; et al. (2015). "Same-Admission Versus Interval Cholecystectomy for Mild Gallstone Pancreatitis (PONCHO): A Multicentre Randomised Controlled Trial". Lancet. 386 (10000): 1261–1268. doi:10.1016/S0140-6736(15)00274-3. PMID 26460661.
- ↑ Selin D, Oskarsson V, Maret-Ouda J; et al. (2026). "Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography or No Intervention After Gallstone-Related Acute Pancreatitis". JAMA Surg. doi:10.1001/jamasurg.2025.2369.
- ↑ McDermott J, Kao LS, Keeley JA, Nahmias J, de Virgilio C (2024). "Management of Gallstone Pancreatitis: A Review". JAMA Surg. doi:10.1001/jamasurg.2024.2580.
- ↑ Trikudanathan G, Yazici C, Evans Phillips A, Forsmark CE (2024). "Diagnosis and Management of Acute Pancreatitis". Gastroenterology. 167 (4): 673–688. doi:10.1053/j.gastro.2024.02.052.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Baron TH, DiMaio CJ, Wang AY, Morgan KA (2020). "American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis". Gastroenterology. 158 (1): 67–75.e1. doi:10.1053/j.gastro.2019.07.064.
- ↑ Boxhoorn L, Voermans RP, Bouwense SA; et al. (2020). "Acute Pancreatitis". Lancet. 396 (10252): 726–734. doi:10.1016/S0140-6736(20)31310-6.
- ↑ 8.0 8.1 Boxhoorn L, van Dijk SM, van Grinsven J; et al. (2021). "Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis". N Engl J Med. 385: 1372–1381. doi:10.1056/NEJMoa2100826.
- ↑ 9.0 9.1 9.2 9.3 van Santvoort HC, Besselink MG, Bakker OJ; et al. (2010). "A Step-Up Approach or Open Necrosectomy for Necrotizing Pancreatitis". N Engl J Med. 362 (16): 1491–1502. doi:10.1056/NEJMoa0908821. PMID 20410514.
- ↑ 10.0 10.1 10.2 Hollemans RA, Bakker OJ, Boermeester MA; et al. (2019). "Superiority of Step-Up Approach vs Open Necrosectomy in Long-Term Follow-Up of Patients With Necrotizing Pancreatitis". Gastroenterology. 156 (4): 1016–1026. doi:10.1053/j.gastro.2018.10.045. PMID 30391468.
- ↑ 11.0 11.1 van Brunschot S, van Grinsven J, van Santvoort HC; et al. (2018). "Endoscopic or Surgical Step-Up Approach for Infected Necrotising Pancreatitis: A Multicentre Randomised Trial". Lancet. 391 (10115): 51–58. doi:10.1016/S0140-6736(17)32404-2.
- ↑ Onnekink AM, Boxhoorn L, Timmerhuis HC; et al. (2022). "Endoscopic Versus Surgical Step-Up Approach for Infected Necrotizing Pancreatitis (ExTENSION): Long-Term Follow-Up of a Randomized Trial". Gastroenterology. 163 (3): 712–722.e4.
- ↑ 13.0 13.1 Bang JY, Arnoletti JP, Holt BA; et al. (2019). "An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis". Gastroenterology. 156 (4): 1027–1040.e3. doi:10.1053/j.gastro.2018.11.031. PMID 30452918.
- ↑ Bakker OJ, van Santvoort HC, van Brunschot S; et al. (2012). "Endoscopic Transgastric vs Surgical Necrosectomy for Infected Necrotizing Pancreatitis: A Randomized Trial". JAMA. 307 (10): 1053–1061. doi:10.1001/jama.2012.276. PMID 22416101.
- ↑ Dayyeh BKA, Chandrasekhara V, Shah RJ; et al. (2023). "Combined Drainage and Protocolized Necrosectomy Through a Coaxial Lumen-Apposing Metal Stent for Pancreatic Walled-Off Necrosis: A Prospective Multicenter Trial". Ann Surg. 277 (5): e1006–e1013. PMID 35129503 Check
|pmid=value (help). - ↑ Boxhoorn L, Verdonk RC, Besselink MG; et al. (2023). "Comparison of Lumen-Apposing Metal Stents Versus Double-Pigtail Plastic Stents for Infected Necrotising Pancreatitis". Gut. 72 (1): 66–72. PMID 35701094 Check
|pmid=value (help). - ↑ Holanda EU, Fondelli AA, de Freitas Kleimmann R; et al. (2025). "Metal Stents Versus Plastic Stents for Drainage of Pancreatic Fluid Collections: A Systematic Review and Meta-Analysis of Randomized Trials With Trial Sequential Analysis". Surg Endosc. 39 (3). PMID 39849071 Check
|pmid=value (help). - ↑ Saito T, Fujisawa T, Ogura T; et al. (2026). "Immediate or on-Demand Endoscopic Necrosectomy for Necrotizing Pancreatitis: A Randomized Controlled Trial (WONDER-01)". Gastroenterology. 171 (1): 140–153. doi:10.1053/j.gastro.2026.01.034. PMID 41720198 Check
|pmid=value (help). - ↑ Mohamadnejad M, Hassanzadeh M, Anushirvani A; et al. (2026). "Immediate vs on-Demand Endoscopic Necrosectomy in Infected Walled-Off Pancreatic Necrosis: A Randomized Controlled Trial". Clin Gastroenterol Hepatol.
- ↑ Dimitrov D, Wu Y, Rodriguez B, Qatomah A, Ramai D (2026). "Immediate vs Step-Up Endoscopic Transluminal Necrosectomy in Necrotizing Pancreatitis: Systematic Review and Meta-Analysis of Randomized Controlled Trials". Endoscopy. PMID 42503311 Check
|pmid=value (help). - ↑ 21.0 21.1 Maurer LR, Fagenholz PJ (2023). "Contemporary Surgical Management of Pancreatic Necrosis". JAMA Surg. doi:10.1001/jamasurg.2023.3283.