Endoscopic transluminal interventions in the management of acute infected necrotizing pancreatitis. Literature review

Abstract

Acute necrotizing pancreatitis remains one of the most challenging diseases in general surgery. Infection of necrotic tissue, sepsis, and organ failure are the main determinants of mortality in this pathology. Other lifethreatening complications include intestinal obstruction, biliary obstruction, abdominal compartment syndrome, external fistulas, bleeding, and thrombosis of the splenic and portal veins. The formation of walled-off necrosis after the fourth week of disease creates anatomical conditions for a transluminal endoscopic access to the pathological focus when appropriate indications are present. Current management of acute necrotizing pancreatitis is based on a step-up minimally invasive strategy in which endoscopic interventions occupy a leading role. International clinical guidelines, particularly those of ESGE, AGA, and ASGE, support the endoscopic step-up approach as first-line therapy for infected walled-off necrosis. This strategy focuses on controlling septic manifestations rather than performing immediate necrosectomy. Key factors for success include appropriate timing of intervention, a multidisciplinary approach, and individualization of the treatment strategy. The optimal indications for escalation to more invasive procedures remain unresolved and are subject to ongoing debate, often depending on the experience of a particular specialized center. The complexity of clinical decision-making may also be related to differences in treatment approaches between general surgeons and endoscopists, which necessitates a balanced interdisciplinary collaboration.