title: Surgical treatment of acute pancreatitis.
abstract: BACKGROUND
  Acute pancreatitis remains an unpredictable, potentially lethal disease with significant morbidity and mortality rates. New insights in the pathophysiology of acute pancreatitis have changed management concepts. In the first phase, characterized by a systemic inflammatory response syndrome, organ failure, not related to infection but rather to severe inflammation, dominates the focus of treatment. In the second phase, secondary infectious complications largely determine the clinical outcome. As infection is associated with increased mortality in acute pancreatitis, numerous prophylactic strategies have been explored in the past two decades.
  
  
  OBJECTIVE
  This review describes the strategies that have been developed to lower the infection rate, in an attempt to lower mortality. Antibiotic prophylaxis has been the subject of many RCT's without showing convincing evidence of their efficacy. Probiotics, although theoretically capable of lowering the rate of infection, also had no effect on infectious complications, and consequently, no effective strategy to lower the rate of infectious complications is currently available. In the second part of this review, new approaches for necrosectomy that have been designed by different centers around the world are discussed. All the interventional techniques have in common their aim to lower the invasive character, hypothesizing that lowering the surgical trauma will improve survival and lower complication rates. Recent advances include postponing intervention as a strategy to facilitate necrosectomy and improve prognosis and the "step-up approach" in case of infected necrosis. The step-up approach includes percutaneous catheter drainage as the first step, to be followed by necrosectomy, either through a minimally invasive approach or by open necrosectomy, as the next step.
  
  
  CONCLUSIONS
  All attempts to develop treatment strategies to lower the infection rate in acute pancreatitis have failed. Accumulating evidence is emerging to show that the combination of centralization, the use of catheter drainage as the first step of invasive treatment, and the development of minimally invasive techniques, improve the outlook for patients with infected necrosis. It is uncertain at this point in time as to which of the three effects is dominant in the improvement of prognosis.
authors.affiliation: Department of Operating Rooms-Evidence based surgery, Radboud University Nijmegen Medical Centre, PO BOX 9101, 6500, HB Nijmegen, The Netherlands. h.gooszen@ok.umcn.nl
authors.forename: Hein G
authors.initials: HG
authors.lastname: Gooszen
authors.forename: Marc G H
authors.initials: MG
authors.lastname: Besselink
authors.forename: Hjalmar C
authors.initials: HC
authors.lastname: van Santvoort
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Bollen
mesh_terms: D019072:Antibiotic Prophylaxis; D004322:Drainage / Q000379:methods*; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D009336:Necrosis / Q000601:surgery; D019283:Pancreatitis, Acute Necrotizing / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D011379:Prognosis; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012720:Severity of Illness Index; D013530:Surgical Wound Infection / Q000517:prevention & control; D015996:Survival Rate; D016896:Treatment Outcome