Sit on your Hands, Dear Surgeon – Delayed Intervention and Medical Optimization in Necrotizing Pancreatitis Improves Outcomes

Abstract Purpose Decades of research has consistently demonstrated the advantage of a step-up approach for the treatment of pancreatic necrosis. However, the key to improved outcomes relies more on patience than the specific approach with a recent shift towards the importance of delayed intervention and medical optimization. This review breaks down ways to medically optimize patients with sterile and infected pancreatic necrosis, and guide timing of invasive approaches should nonoperative management fail. Recent Findings New data suggests that timing, rather than approach, has the biggest impact on mortality in the management of pancreatic necrosis. While the step-up minimally invasive approach improves morbidity outcomes, delaying procedures by at least four weeks improves morbidity and mortality outcomes. Multidisciplinary supportive care is the primary management for patients with pancreatic necrosis. For patients with clinical deterioration or persistent lifestyle-limiting symptoms despite supportive care, a stepwise approach is best summarized by the mantra delay , drain , debride , with emphasis on “delay”. If intervention is ultimately required, a step-up approach should be followed: drainage (percutaneous and/or endoscopic), endoscopic necrosectomy, video-assisted necrosectomy, and then open necrosectomy in select cases. For each step, clinical improvement or deterioration dictates whether a patient needs to advance to the next tier. Regardless, earlier intervention does not improve outcomes. Summary Supportive care followed by a stepwise mantra of delay , drain , debride provides the best outcomes for patients with pancreatic necrosis, whether infected or sterile. Intervention shoulder be pursued in a step-up fashion, and no advantage to intervention earlier than 4 weeks has been identified.