Acute Pancreatitis

The clinical presentation, diagnosis, and classification of acute pancreatitis are described in the 2012 Revised Atlanta Classification. Traditionally, but now under debate, the course of acute pancreatitis has been described as a biphasic course with two peaks of mortality: early and late. In the first weeks there are signs of a systemic inflammatory response syndrome; the weeks and months afterward are characterized by a compensatory antiinflammatory response syndrome. Reducing the change of secondary infection of (peri)pancreatic necrosis by early enteral feeding or probiotics has shown no beneficial results. The role of an endoscopic sphincterotomy in predicted severe acute pancreatitis and without cholangitis is still under debate. After recovery of mild biliary pancreatitis, there is an indication for an early cholecystectomy. Based on the 2013 International Association of Pancreatology (IAP)/American Pancreatic Association (APA) evidence-based guideline, the main indication for intervention in necrotizing pancreatitis is infected necrosis. When infection is proven or suspected, invasive interventions should be preferably delayed until at least 4 weeks after onset of disease to allow collections to become “walled-off.” Based on the surgical “step-up approach,” the first step is percutaneous catheter drainage. After catheter drainage, 65% of patients need necrosectomy. The preferred route of necrosectomy is minimally invasive. In infected necrosis, the surgical step-up approach is superior to a laparotomy and can alternatively be done endoscopically (transgastric catheter drainage and endoscopic necrosectomy). The TENSION trial compares the surgical and endoscopic step-up approach and results are expected in 2017.