Acute Pancreatitis Surgical Timing - IAP/APA Guidelines

Algorithm Steps

1. ▶

   Start

   Severe Acute Pancreatitis with Necrosis

   CT-confirmed pancreatic/peripancreatic necrosis

   1. ●

      Action

      Severity Assessment

      Atlanta classification, organ failure

      • Persistent organ failure >48h = severe
      • CT severity index
      • APACHE II, BISAP scores
      1. ◆

         Decision

         Infected Necrosis?

         • Gas in collection (CT)
         • FNA showing bacteria/fungi
         • Clinical deterioration/sepsis
         1. ●

            Action

            Sterile Necrosis

            Conservative management usually

            1. ●

               Action

               Conservative Management

               ICU care, nutrition, wait

               • Enteral nutrition (NJ preferred)
               • No role for prophylactic antibiotics
               • Repeat imaging at 7-10 days
               • Intervene only if infected or symptomatic
               1. ■

                  End

                  Resolution & Follow-up

                  Manage exocrine/endocrine insufficiency, cholecystectomy if biliary

               2. ●

                  Action

                  Infected Necrosis

                  Intervention needed

                  1. ◆

                     Decision

                     Timing of Intervention

                     • Delay until WON (≥4 weeks)
                     • Bridge with antibiotics, nutrition
                     • Earlier if septic/deteriorating
                     1. ●

                        Action

                        Step-Up Approach

                        Start minimally invasive

                        • 1. Percutaneous/endoscopic drainage
                        • 2. If fails: video-assisted debridement
                        • 3. Open necrosectomy only if needed
                        1. ●

                           Action

                           Percutaneous/EUS Drainage

                           First step of intervention

                           • CT-guided drain for PFC
                           • EUS-guided for WON access
                           • Multiple drains may be needed
                           1. ●

                              Action

                              Minimally Invasive Debridement

                              If drainage insufficient

                              • VARD (video-assisted)
                              • DEN (direct endoscopic necrosectomy)
                              • Transgastric or retroperitoneal
                              1. ●

                                 Action

                                 Open Necrosectomy

                                 Last resort

                                 • If minimally invasive fails
                                 • Severe sepsis requiring source control
                                 • Higher morbidity/mortality