Minimally invasive intervention in severe acute pancreatitis: a critical, decision-oriented review of timing, route, and escalation

Abstract

Severe acute pancreatitis (SAP) is a heterogeneous and potentially fatal disease in which infected necrosis, persistent organ failure, and procedure-related morbidity remain major clinical challenges. Although minimally invasive intervention has largely replaced early open necrosectomy, important uncertainties persist regarding the optimal timing of intervention, the choice of initial access route, and the threshold for escalation beyond drainage alone. This review synthesizes current evidence on minimally invasive management of SAP with a particular focus on unresolved controversies and decision-making in real-world practice. Rather than viewing percutaneous, endoscopic, and minimally invasive surgical techniques as competing modalities, we propose that they should be understood as complementary tools within an individualized step-up strategy. In our view, the most meaningful clinical question is not whether minimally invasive treatment is preferable to open surgery, but how intervention should be tailored according to indication, urgency, collection maturity, anatomical distribution, solid necrotic burden, septic trajectory, and local multidisciplinary expertise. Based on these considerations, we present a practical decision-centered framework to guide route selection, timing, and escalation. Future research should move beyond broad modality comparisons toward anatomy-stratified studies, standardized escalation criteria, and long-term patient-centered outcomes.

Keywords

Severe acute pancreatitis / minimally invasive treatment / step-up approach / multidisciplinary team management

References

[1] Iannuzzi JP,Leong JH.Global incidence of acute pancreatitis is increasing over time: a systematic review and meta-analysis.Gastroenterology2022;162:122-34

[2] Mehta V,Parkash S.Role of percutaneous catheter drainage as primary treatment of necrotizing pancreatitis.Turk J Gastroenterol2019;30:184-7 PMCID:PMC6408166

[3] Boxhoorn L,Bouwense SA.Acute pancreatitis.Lancet2020;396:726-34

[4] Tenner S,Sheth SG.American college of gastroenterology guidelines: management of acute pancreatitis.Am J Gastroenterol2024;119:419-37 PMCID:PMC13221274

[5] Leppäniemi A,Tarasconi A.2019 WSES guidelines for the management of severe acute pancreatitis.World J Emerg Surg2019;14:27 PMCID:PMC6567462

[6] Li H, Wang P, Han J, Jin Y, Wang Z. Minimally invasive intervention in severe acute pancreatitis: a critical, decision-oriented review of timing, route, and escalation. ScieRxiv. 2026; 2026040234. Available from: https://doi.org/10.20517/scierxiv202604.0234.v1. [accessed 15 Jul 2026]

[7] Palumbo R.Contemporary management of acute pancreatitis: what you need to know.J Trauma Acute Care Surg2024;96:156-65

[8] Mier J,Castillo A,Blanco R.Early versus late necrosectomy in severe necrotizing pancreatitis.Am J Surg1997;173:71-5

[9] Matteucci M,Guarino S.Minimally invasive approach versus open approach in the management of necrotizing acute pancreatitis: a systematic review and meta-analysis.Ann Hepatobiliary Pancreat Surg2025;29:226-39 PMCID:PMC12377997

[10] Bang JY,Holt BA.An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis.Gastroenterology2019;156:1027-40.e3

[11] Gao L, Zhang H, Li G, et al.; Chinese Acute Pancreatitis Clinical Trials Group (CAPCTG). The clinical outcome from early versus delayed minimally invasive intervention for infected pancreatic necrosis: a systematic review and meta-analysis.J Gastroenterol2022;57:397-406

[12] Li G,Huang MF.Involvement of transverse mesocolon is associated with development of colonic fistula in patients with acute necrotizing pancreatitis.Pancreatology2023;23:314-20

[13] van Brunschot S, van Grinsven J, van Santvoort HC, et al.; Dutch Pancreatitis Study Group. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial.Lancet2018;391:51-8

[14] Valentin C,Tuyeras G.Step-up approach for the treatment of infected necrotising pancreatitis: real life data from a single-centre experience with long-term follow-up.BMC Gastroenterol2024;24:213 PMCID:PMC11214239

[15] Baron TH,Wang AY.American Gastroenterological Association clinical practice update: management of pancreatic necrosis.Gastroenterology2020;158:67-75.e1

[16] Hollemans RA, Bakker OJ, Boermeester MA, et al.; Dutch Pancreatitis Study Group. Superiority of step-up approach vs open necrosectomy in long-term follow-up of patients with necrotizing pancreatitis.Gastroenterology2019;156:1016-26

[17] Paramythiotis D,Tsavdaris D.When to intervene in acute necrotizing pancreatitis: a narrative review of the optimal timing for intervention strategies.Medicina2024;60:1592 PMCID:PMC11509130

[18] Tang P,Khizar H.Endoscopic versus minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials.Ann Med2023;55:2276816 PMCID:PMC10629416

[19] Hamesch K,Guilabert L,Koch A.Practical management of severe acute pancreatitis.Eur J Intern Med2025;133:1-13

[20] Büchler MW,Müller CA,Seiler CA.Acute necrotizing pancreatitis: treatment strategy according to the status of infection.Ann Surg2000;232:619-26 PMCID:PMC1421214

[21] Boxhoorn L, van Dijk SM, van Grinsven J, et al.; Dutch Pancreatitis Study Group. Immediate versus postponed intervention for infected necrotizing pancreatitis.N Engl J Med2021;385:1372-81

[22] Sahu SK,Das S.Approach to the diagnosis and management of infected pancreatic necrosis: a narrative review.Cureus2025;17:e83020 PMCID:PMC12104691

[23] Shah J,Jagodzinski R.Infected pancreatic necrosis - current trends in management.Indian J Gastroenterol2024;43:578-91

[24] Banks PA, Bollen TL, Dervenis C, et al.; Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis - 2012: revision of the Atlanta classification and definitions by international consensus.Gut2013;62:102-11

[25] Bu M,Xie X.Influencing factor analysis and clinical efficacy of early intervention in severe acute pancreatitis with persistent organ failure.Sci Rep2025;15:16230 PMCID:PMC12064800

[26] Rainho A,Strand DS.Pancreatic necrosis: a scoping review.Minerva Gastroenterol2025;71:48-64

[27] Garg PK.Organ failure due to systemic injury in acute pancreatitis.Gastroenterology2019;156:2008-23 PMCID:PMC6486861

[28] Brown LA,Phillips AR,Petrov MS.A systematic review of the extra-pancreatic infectious complications in acute pancreatitis.Pancreatology2014;14:436-43

[29] Ben-Ami Shor D, Ritter E, Borkovsky T, Santo E. The multidisciplinary approach to acute necrotizing pancreatitis.J Clin Med2025;14:2904 PMCID:PMC12072366

[30] Kirkpatrick AW, Roberts DJ, De Waele J, et al.; Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome.Intensive Care Med2013;39:1190-206 PMCID:PMC3680657

[31] Boone B,Hughes SJ.Abdominal compartment syndrome is an early, lethal complication of acute pancreatitis.Am Surg2013;79:601-7

[32] Noh BG,Park YM.Successful resolution of gastric perforation caused by a severe complication of pancreatic walled-off necrosis: a case report.World J Clin Cases2023;11:6298-303 PMCID:PMC10507535

[33] Xu J,Zhang C,Li Y.Management of abdominal compartment syndrome in severe acute pancreatitis patients with early continuous veno-venous hemofiltration.Hepatogastroenterology2013;60:1749-52

[34] Valverde-López F, Han S, Coughlin S, et al.; Collaborative Alliance for Pancreatic Education and Research. Outcomes of endoscopic management of sterile walled-off pancreatic necrosis: a systematic review.Pancreas2021;50:1357-62

[35] Zhang H,Mao WJ.Early versus delayed intervention in necrotizing acute pancreatitis complicated by persistent organ failure.Hepatobiliary Pancreat Dis Int2022;21:63-8

[36] Ignatavicius P,Cernauskis K,Dambrauskas Z.How severe is moderately severe acute pancreatitis? Clinical validation of revised 2012 Atlanta Classification.World J Gastroenterol2017;23:7785-90 PMCID:PMC5703938

[37] Hu WM,Zhang YL.Prognostic significance of organ failure and infected pancreatic necrosis in acute pancreatitis: an updated systematic review and meta-analysis.J Dig Dis2023;24:648-59

[38] Troncone E,Gadaleta F.Indications, techniques and future perspectives of walled-off necrosis management.Diagnostics2024;14:381 PMCID:PMC10888331

[39] Szeliga J,Sobocki J.Diagnostic and therapeutic management of severe acute pancreatitis. Evidence based medicine (EBM) clinical practice guidelines.Wideochir Inne Tech Maloinwazyjne2025;20:1-29 PMCID:PMC12177351

[40] Mo Q.Minimally invasive step-up surgery demonstrates superior suitability over open surgery in severe acute pancreatitis.Am J Transl Res2025;17:7039-46 PMCID:PMC12531502

[41] Mihoc T,Dobrescu A.Risk factors influencing mortality in open necrosectomy for acute pancreatitis: a comparative analysis.J Clin Med2024;13:7151 PMCID:PMC11642430

[42] Masood M,Krishnamoorthi R,Fotoohi M.Interventional management of acute pancreatitis and its complications.J Clin Med2025;14:6683 PMCID:PMC12470711

[43] IAP/APA/EPC/IPC/JPS Working Group. International Association of Pancreatology revised guidelines on Acute Pancreatitis 2025: supported and endorsed by the American Pancreatic Association, European Pancreatic Club, Indian Pancreas Club, and Japan Pancreas Society.Pancreatology2025;25:770-814

[44] Subasinghe D,Fernandopulle N,Sivaganesh S.Surgery for necrotizing acute pancreatitis: surgical approach, morbidity and challenges encountered: experience from a tertiary care hepatopancreatobiliary unit in Sri Lanka.Front Surg2026;13:1709496 PMCID:PMC12983089

[45] Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis.Pancreatology2013;13:e1-15

[46] Tenner S, Baillie J, DeWitt J, Vege SS; American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis.Am J Gastroenterol2013;108:1400-15

[47] Basha J,Lakhtakia S.Endoscopic step-up approach in management of necrotizing pancreatitis.Gastroenterol Clin North Am2025;54:37-51

[48] Bang JY, Lakhtakia S, Thakkar S, et al.; United States Pancreatic Disease Study Group. Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial.Lancet Gastroenterol Hepatol2024;9:22-33

[49] Onnekink AM, Boxhoorn L, Timmerhuis HC, et al.; Dutch Pancreatitis Study Group. Endoscopic versus surgical step-up approach for infected necrotizing pancreatitis (ExTENSION): long-term follow-up of a randomized trial.Gastroenterology2022;163:712-22.e14

[50] Ning C,Shen D.Is contemporary open pancreatic necrosectomy still useful in the minimally invasive era?.Surgery2024;175:1394-401

[51] Mastronardi M,Crociato S.Endoscopic versus surgical management for infected necrotizing pancreatitis and walled-off necrosis: a systematic review of randomized controlled trials.Medicina2025;61:2149 PMCID:PMC12734442

[52] Zerem E,Omerović S.Randomized controlled trial on sterile fluid collections management in acute pancreatitis: should they be removed?.Surg Endosc2009;23:2770-7

[53] Liu Y,Wang H,Fu X.Application and value of percutaneous catheter drainage in contemporary surgical treatment of pancreatic necrosis.Dig Dis Sci2025;70:2977-89 PMCID:PMC12411323

[54] Samanta J,Muktesh G.Endoscopic drainage versus percutaneous drainage for the management of infected walled-off necrosis: a comparative analysis.Expert Rev Gastroenterol Hepatol2022;16:297-305

[55] Khan MA,Khan Z.Endoscopic versus percutaneous management for symptomatic pancreatic fluid collections: a systematic review and meta-analysis.Endosc Int Open2018;6:E474-83 PMCID:PMC5876036

[56] Freeny PC,Althaus SJ,Sinanan M.Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results.AJR Am J Roentgenol1998;170:969-75

[57] Gupta P,Padmanabhan A.Indian College of Radiology and Imaging Consensus guidelines on interventions in pancreatitis.Indian J Radiol Imaging2022;32:339-54 PMCID:PMC9514912

[58] Earjala JK,Govindaraj Raman SK.Step-up management in acute pancreatitis: a tertiary care center’s experience from Southern India.Cureus2024;16:e58971 PMCID:PMC11128138

[59] Portelli M.Severe acute pancreatitis: pathogenesis, diagnosis and surgical management.Hepatobiliary Pancreat Dis Int2017;16:155-9

[60] Rana SS.Endoscopic treatment of pancreatic necrosis: still searching for perfection!.J Gastroenterol Hepatol2023;38:1252-8

[61] Arvanitakis M,Albert J.Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines.Endoscopy2018;50:524-46

[62] Mukai S,Tsuchiya T.Endoscopic step-up approach for walled-off necrosis after acute pancreatitis.DEN Open2026;6:e70188 PMCID:PMC12375900

[63] Nakai Y,Hamada T.Controversies in endoscopic ultrasonography-guided management of walled-off necrosis.Dig Endosc2025;37:29-39

[64] Nemoto Y,Arain MA.Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: outcomes in a large cohort of patients.Pancreatology2017;17:663-8

[65] Tsiotos GG,Sarr MG.Long-term outcome of necrotizing pancreatitis treated by necrosectomy.Br J Surg1998;85:1650-3

[66] van Santvoort HC, Besselink MG, Bakker OJ, et al.; Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis.N Engl J Med2010;362:1491-502

[67] Vuthaluru AR,Goyal O,Goyal MK.The evolving role of endoscopic ultrasound-guided lumen-apposing metal stents in the management of peri-pancreatic fluid collections.Ther Adv Gastroenterol2025;18:17562848251353627 PMCID:PMC12228923

[68] Kleemann T,Braden B.An international survey on the geographical differences in practice patterns and training of endoscopic ultrasound.J Transl Int Med2025;13:48-64 PMCID:PMC11921813

[69] Wan R,Tong Y,Shen B.Efficiency of laparoscopic retroperitoneal pancreatic necrosectomy for treating infected pancreatic necrosis with duodenal fistula: a single-center retrospective cohort study.BMC Gastroenterol2024;24:477 PMCID:PMC11673563

[70] Tonsi AF,Crippa S,Bassi C.Acute pancreatitis at the beginning of the 21st century: the state of the art.World J Gastroenterol2009;15:2945-59 PMCID:PMC2702102

[71] Wani SV,Mathur SK.Minimally invasive approach to pancreatic necrosectomy.J Laparoendosc Adv Surg Tech A2011;21:131-6

[72] Bello B.Minimally invasive treatment of pancreatic necrosis.World J Gastroenterol2012;18:6829-35 PMCID:PMC3520172

[73] Feng L,Wang S.Endoscopic transmural drainage and necrosectomy in acute necrotizing pancreatitis: a review.J Transl Int Med2021;9:168-76 PMCID:PMC8629413

[74] Maatman TK.Surgical step-up approach in management of necrotizing pancreatitis.Gastroenterol Clin North Am2025;54:53-74

[75] Hozaka Y,Mataki Y.Successful treatment for severe pancreatitis with colonic perforation using video-assisted retroperitoneal debridement: a case report.Int J Surg Case Rep2018;52:23-7 PMCID:PMC6176850

[76] Hu Y,Li C.Outcomes from different minimally invasive approaches for infected necrotizing pancreatitis.Medicine2019;98:e16111 PMCID:PMC6587624

[77] Eickhoff RM,Seppelt P.[Video-assisted retroperitoneal debridement : Minimally invasive treatment and long-term results for necrotizing pancreatitis].Chirurg2017;88:785-91

[78] Zhu S,Sun Z.Minimal access retroperitoneal pancreatic necrosectomy for infected pancreatic necrosis: a single-center of 15 years’ experience.Surgery2025;183:109392

[79] Piaścik M,Milewski J.The results of severe acute pancreatitis treatment with continuous regional arterial infusion of protease inhibitor and antibiotic: a randomized controlled study.Pancreas2010;39:863-7

[80] Matsumoto K,Nakatsu M.Usefulness of early-phase peritoneal lavage for treating severe acute pancreatitis.Intern Med2014;53:1-6

[81] Hirota M,Kitamura K.Continuous regional arterial infusion versus intravenous administration of the protease inhibitor nafamostat mesilate for predicted severe acute pancreatitis: a multicenter, randomized, open-label, phase 2 trial.J Gastroenterol2020;55:342-52 PMCID:PMC7026212

[82] Chen HM,Hwang TL,Chen MF.Prospective and randomized study of gabexate mesilate for the treatment of severe acute pancreatitis with organ dysfunction.Hepatogastroenterology2000;47:1147-50

[83] Cerrato Delgado S, Valverde Martinez A, Gómez Sánchez T, Fierro Aguilar A, Pacheco García JM. Step-up approach in severe necrotizing pancreatitis: combination of video-assisted retroperitoneal debridement and endoscopic necrosectomy.Cir Esp2022;100:52-5

[84] Beij A,van Santvoort HC,Voermans RP.Acute pancreatitis: an update of evidence-based management and recent trends in treatment strategies.United European Gastroenterol J2025;13:97-106 PMCID:PMC11866315

[85] Vaidya K,Nagtode T,Goel S.Role of necrosectomy in necrotizing pancreatitis: a narrative review.Cureus2024;16:e70470 PMCID:PMC11522170

[86] Bomman S,Masood M.Early versus late drainage of pancreatic necrotic fluid collections: a systematic review and meta-analysis.Ann Gastroenterol2025;38:221-9 PMCID:PMC11928901

[87] Ke L, Li G, Mao W, et al.; Chinese Acute Pancreatitis Clinical Trials Group (CAPCTG). Early versus delayed catheter drainage for patients with necrotizing pancreatitis and early persistent organ failure (TIMING): a multicenter randomized controlled trial.Intensive Care Med2025;51:1431-41

[88] van Santvoort HC, Bakker OJ, Bollen TL, et al.; Dutch Pancreatitis Study Group. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome.Gastroenterology2011;141:1254-63

[89] Heckler M,Hu K,Büchler MW.Severe acute pancreatitis: surgical indications and treatment.Langenbecks Arch Surg2021;406:521-35 PMCID:PMC8106572

[90] Sagar AJ,Tapuria N.Evidence-based approach to the surgical management of acute pancreatitis.Surg J2022;8:e322-35 PMCID:PMC9681540

[91] Li G,Cao L.Nomogram development and validation for predicting minimally invasive step-up approach failure in infected necrotizing pancreatitis patients: a retrospective cohort study.Int J Surg2023;109:1677-87 PMCID:PMC10389492

[92] Purschke B,Meyer MN.Interventional strategies in infected necrotizing pancreatitis: indications, timing, and outcomes.World J Gastroenterol2022;28:3383-97 PMCID:PMC9346450

[93] Zerem E,Sušić A.Step-up approach to infected necrotising pancreatitis: a 20-year experience of percutaneous drainage in a single centre.Dig Liver Dis2011;43:478-83

[94] Pancreas Study Group, Chinese Society of Gastroenterology, Chinese Medical Association. Practice guidance for diagnosis and treatment of pancreatitis-related splanchnic vein thrombosis (Shenyang, 2020).J Dig Dis2021;22:2-8

[95] Trikudanathan G,Attam R.Interventions for necrotizing pancreatitis: an overview of current approaches.Expert Rev Gastroenterol Hepatol2013;7:463-75

[96] Yin J,Niu W.Using a multidisciplinary team for the staged management and optimally minimally invasive treatment of severe acute pancreatitis.Biosci Trends2021;15:180-7

[97] Nayar MK,Bourne D.Novel multidisciplinary hub-and-spoke tertiary service for the management of severe acute pancreatitis.BMJ Open Gastroenterol2021;8:e000501 PMCID:PMC8016076