Clinical and surgical approaches in the management of acute pancreatitis. A comprehensive review

Nº de DOI: 10.34896/RSI.2025.81.31.001

 AUTHORS

1. Pablo Andres Montaño Ucho. General Practitioner. Attached to the Pablo Jaramillo Crespo Humanitarian Hospital Foundation. Independent Researcher at the Matilde Hidalgo of Procel Research and Teaching Department. Graduate of the University of Cuenca. (⁠Cuenca-Ecuador). https://orcid.org/0009-0008-5216-3561
2. Carlos Xavier Cabrera Angüisaca. General Practitioner. Attached to Catacocha Basic Hospital. Graduate of the University of Cuenca. (Cuenca-Ecuador). https://orcid.org/0009-0000-3366-4151
3. Cristian Santiago Mencías Ríos. General Practitioner. Attached to the Punin Type A Health Centre. Graduate of the Chimborazo Higher Polytechnic School. (Riobamba-Ecuador). https://orcid.org/0009-0001-5222-1687
4. María José Trujillo Avalos. General Practitioner. Attached to Guamote Basic Hospital. Graduate of the National University of Chimborazo. (Riobamba-Ecuador). https://orcid.org/0009-0008-5404-3440
5. Lissette Emileny Quizhpe Palaquibay. General Practitioner and Master’s Degree in Clinical Patient Safety and Healthcare Quality Management. Attached to Ecuadros Private Clinics. Graduate of the University of Guayaquil. (Duran-Ecuador). https://orcid.org/0009-0006-2764-0552

ABSTRACT

This review aims to synthesize the current knowledge on the pathophysiology, clinical presentation, diagnostic criteria, and management strategies—both medical and surgical—in acute pancreatitis, providing a thorough overview of the approaches employed to improve patient outcomes and guide future research in this challenging domain.

KEY WORDS

Acute pancreatitis, clinical management, surgical treatment, minimally invasive surgery, conservative treatment, pancreatic necrosis and outcomes.

RESUMEN

Esta revisión busca sintetizar el conocimiento actual sobre la fisiopatología, la presentación clínica, los criterios diagnósticos y las estrategias de manejo, tanto médicas como quirúrgicas, de la pancreatitis aguda. Ofrece una visión general exhaustiva de los enfoques empleados para mejorar los resultados de los pacientes y orientar la investigación futura en este complejo campo.

PALABRAS CLAVE

Pancreatitis aguda, manejo clínico, tratamiento quirúrgico, cirugía mínimamente invasiva, tratamiento conservador, necrosis pancreática y resultados.

INTRODUCTION

Acute pancreatitis is a complex and potentially life-threatening inflammatory condition of the pancreas that poses significant challenges in clinical management due to its diverse etiologies, variable severity, and multifaceted treatment approaches. Characterized by an abrupt onset of abdominal pain, often accompanied by nausea, vomiting, and systemic inflammatory responses, its diagnosis relies on specific clinical criteria, laboratory findings, and imaging modalities that delineate the extent of pancreatic injury. The underlying pathophysiology involves premature activation of pancreatic enzymes, leading to autodigestion, inflammation, and possible local or systemic complications, which necessitate prompt recognition and tailored management strategies. Currently, the cornerstone of initial treatment centers on supportive care, including aggressive fluid resuscitation, pain control, and nutritional support, with pharmacological interventions playing a supplementary role in mitigating inflammation and managing complications. While conservative management remains the mainstay for most cases, certain severe or complicated presentations require surgical intervention, either through traditional open procedures or minimally invasive techniques such as endoscopic or laparoscopic approaches, which aim to reduce morbidity and improve recovery outcomes. The decision-making process regarding surgical versus non-surgical management hinges on factors such as disease severity, presence of necrosis, and response to initial therapy. Despite advances in medical and surgical techniques, controversies persist concerning optimal timing, indications, and choice of intervention, underscoring the need for a comprehensive understanding of current guidelines and evolving evidence.

OBJECTIVE

To summarise current knowledge on the pathophysiology, clinical presentation, diagnostic criteria, and medical and surgical management strategies for acute pancreatitis, providing a comprehensive overview of the approaches used to improve patient outcomes and guide future research in this challenging field.

METHODOLOGY

The methodology for this scientific review article, titled “Clinical and Surgical Approaches in the Management of Acute Pancreatitis: A Comprehensive Review,” employs a structured and systematic strategy to identify, evaluate, and synthesize relevant literature on the contemporary management of acute pancreatitis (AP). A comprehensive search is conducted across key biomedical databases including PubMed, Scopus, Embase, and the Cochrane Library. The search strategy incorporates a combination of MeSH terms and free-text keywords such as “acute pancreatitis”, “clinical management”, “surgical treatment”, “minimally invasive surgery”, “conservative treatment”, “pancreatic necrosis” and “outcomes”. Boolean operators and filters are applied to refine results to human studies published in English over the past 20 years.

The quality of included studies is assessed using validated tools appropriate to each study design, such as the Cochrane risk-of-bias tool for randomized trials and the Newcastle-Ottawa Scale for observational studies. Data are synthesized narratively and presented thematically, with tables and figures used to highlight trends, clinical outcomes, and comparative effectiveness across different treatment modalities. The synthesis emphasizes evolving treatment paradigms, including the shift from early aggressive intervention to delayed minimally invasive approaches in cases of infected pancreatic necrosis.

RESULTS

Pathophysiology and Clinical Presentation of Acute Pancreatitis:

What are the underlying mechanisms that lead to acute pancreatitis?

The pathogenesis of acute pancreatitis is rooted in the premature activation of digestive enzymes—particularly zymogen and trypsinogen—within the pancreatic acinar cells, which deviates from their normal activation in the duodenum^1,2. This aberrant activation triggers a self-perpetuating process of auto-digestion, resulting in direct pancreatic tissue injury and subsequent local inflammation^1,2. As the pancreatic acinar cells are destroyed, activated enzymes further facilitate the recruitment of immune cells such as macrophages, granulocytes, monocytes, and lymphocytes to the site of injury, amplifying the inflammatory cascade². The interplay between enzyme activation and immune response not only exacerbates pancreatic damage but also induces the release of pro- and anti-inflammatory cytokines and chemokines, which can escalate the local inflammatory milieu into a systemic inflammatory response syndrome (SIRS) ^1,2. This systemic involvement underscores the interconnectedness between organ-specific injury and multi-organ dysfunction, as unchecked inflammation may progress to multiorgan dysfunction syndrome (MODS), highlighting the critical need for early interventions that target both enzyme activation and the subsequent inflammatory pathways¹.

How do patients with acute pancreatitis typically present clinically?

Clinically, patients with acute pancreatitis almost universally present with sudden onset of severe abdominal pain, which is a hallmark symptom and often signals the beginning of an acute episode^1,3. This pain is characteristically localized to the upper abdomen and may radiate to the back, reflecting the retroperitoneal location of the pancreas and the extent of the inflammatory process³. Frequently, this pain is accompanied by nausea and vomiting, symptoms that further contribute to patient distress and can complicate fluid and electrolyte management³. On physical examination, abdominal tenderness and guarding are commonly observed, indicative of underlying peritoneal irritation and inflammation³. Beyond these clinical manifestations, laboratory evaluation typically reveals elevated serum amylase and lipase levels, which are critical biomarkers aiding in the confirmation of the diagnosis and assessment of disease severity³. The interconnectedness of these domains—pain, gastrointestinal symptoms, physical findings, and laboratory abnormalities—highlights the need for an integrated clinical approach to ensure timely recognition and intervention, ultimately improving patient outcomes in acute pancreatitis.

What are the criteria for diagnosing acute pancreatitis?

In addition to the hallmark symptom of abdominal pain, the diagnosis of acute pancreatitis requires a multidisciplinary approach that incorporates both laboratory and imaging criteria, as outlined in the widely accepted Atlanta criteria⁴. The second core criterion involves the elevation of serum amylase and/or lipase levels to at least three times the upper limit of normal, with lipase testing now considered more sensitive and specific than amylase measurements^4,5. This biochemical increase in pancreatic enzymes serves as a pivotal diagnostic indicator, reflecting the acute inflammatory response and cellular injury within the pancreas⁶. The third criterion is the presence of characteristic findings on imaging studies, such as contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI), which confirm morphological changes consistent with acute pancreatitis⁴. These interconnected domains—clinical presentation, biochemical analysis, and radiological assessment—ensure a comprehensive and accurate diagnosis, emphasizing the need for standardized application of these criteria in clinical practice to optimize patient outcomes and guide timely interventions^4,6.

Medical Management Strategies for Acute Pancreatitis:

What are the current guidelines for fluid resuscitation and supportive care?

Current guidelines for fluid resuscitation and supportive care emphasize the use of crystalloids as the first-line therapy for initial resuscitation and intravascular volume replacement, particularly in patients with sepsis and septic shock [7]. Both balanced crystalloids and saline are recommended, as there is no definitive evidence to suggest a survival advantage between the two, although recent clinical trials such as the SMART trial have demonstrated that buffered solutions may reduce the incidence of major adverse kidney events compared to saline, with the greatest benefits observed in septic patients and those requiring larger fluid volumes⁷. This careful selection of fluids not only impacts kidney outcomes but also interrelates with broader goals of supportive care, including the maintenance of organ perfusion, oxygen delivery, and electrolyte balance, which are vital in stabilizing critically ill patients⁸.Furthermore, guidelines clarify that fluids can be administered enterally when oral intake is possible, but intravenous routes are preferred when patients are unable to ingest fluids, ensuring that ongoing or acute volume losses are promptly replaced to prevent hypoperfusion and organ dysfunction⁸.The multifaceted approach to fluid therapy requires ongoing clinical assessment to gauge the patient’s hemodynamic status and adjust interventions accordingly, underscoring the importance of a coordinated interprofessional team and the need for ongoing research to further refine fluid resuscitation strategies for optimal patient outcomes⁸.

How is nutritional support optimized in patients with acute pancreatitis?

Optimizing nutritional support in patients with acute pancreatitis involves a multifaceted approach that integrates early assessment of nutritional needs, careful selection of feeding routes, and ongoing monitoring to enhance recovery while minimizing complications. Clinical guidelines now advocate for the initiation of enteral nutrition within 24 to 48 hours of hospital admission for patients with severe acute pancreatitis, as this approach helps maintain gut mucosal barrier integrity, prevents bacterial translocation, and stimulates intestinal motility, thereby reducing the risk of systemic infections and improving overall outcomes^9,10. Oral feeding remains the preferred method when tolerated, as it preserves gut function and is associated with fewer complications compared to parenteral strategies; however, if oral intake is not feasible due to persistent symptoms or complications, enteral nutrition via nasojejunal or nasogastric routes is recommended to ensure adequate caloric and protein intake, which are critical for preventing malnutrition and supporting tissue healing⁹. The effectiveness and tolerance of nutritional support must be closely monitored, allowing for timely adjustments tailored to the individual’s clinical status, disease severity, and feeding tolerance, thus underscoring the necessity of an individualized and dynamic approach to nutritional management in acute pancreatitis⁹. Ultimately, a patient-centered, adaptive strategy—integrating early enteral nutrition, vigilant monitoring, and adjustment of nutrient delivery—represents the cornerstone for optimizing nutritional support, reducing morbidity, and improving recovery trajectories in this patient population.

Surgical Interventions and Minimally Invasive Techniques:

When is surgical intervention indicated in acute pancreatitis?

Surgical intervention in acute pancreatitis is primarily indicated when there is clear evidence of infected necrosis, as this complication significantly increases morbidity and mortality if left untreated¹¹. The decision to proceed with surgery is multifaceted and hinges on clinical deterioration, radiological findings of necrosis, and microbiological confirmation of infection, reflecting the necessity of integrating data from multiple domains to optimize patient outcomes¹¹. While conservative management remains the cornerstone of therapy for most cases, surgical intervention becomes essential if infection develops, or if non-surgical measures fail to control complications such as hemorrhage or bowel involvement, highlighting the interconnectedness of pancreatic and extrapancreatic complications that may arise during the disease course^11,12. Historically, early surgical intervention was considered for severe cases, but this approach has been largely abandoned due to the high operative mortality associated with early procedures—sometimes reaching up to 65%—and the realization that early surgery does not confer additional benefit in the absence of infected necrosis¹¹. Advances in intensive care and imaging modalities have further reduced the need for surgical intervention, as improved delineation of necrotic versus viable tissue allows for better patient selection and timing, with current recommendations favoring delayed surgery, ideally 3–4 weeks after onset, to allow demarcation of necrotic tissue and minimize surgical trauma¹¹. This evolution in practice underscores the importance of individualized, evidence-based decision-making and highlights the need for continued research and multidisciplinary collaboration to further refine the indications and timing of surgical intervention in acute pancreatitis.

What are the advantages and limitations of minimally invasive approaches?

Minimally invasive surgical approaches offer substantial advantages across multiple medical domains, notably through smaller incisions that result in less postoperative pain, reduced tissue trauma, and minimized scarring compared to traditional open surgeries^13,14. These benefits not only enhance patient comfort but also translate into shorter hospital stays and quicker recovery times, allowing for earlier return to daily activities and reducing the overall burden on healthcare systems¹⁴. Additionally, the approach decreases the risk of infection and reduces blood loss, which is particularly valuable in patients with comorbidities or heightened risk for surgical complications [13]. However, these advantages are counterbalanced by significant limitations such as restricted surgical visibility and access, which complicate the management of complex or advanced cases and may necessitate conversion to open procedures^13,14. Furthermore, not all conditions are amenable to minimally invasive techniques—a limitation that is especially pronounced in cases of severe pathology or anatomical variations, thereby reducing the overall applicability of these procedures¹⁴. These interconnections highlight the ongoing need for careful patient selection, advanced surgical expertise, and the development of high-quality comparative studies to better delineate the efficacy, safety, and cost-effectiveness of minimally invasive strategies across different specialties. Ultimately, optimizing outcomes in minimally invasive surgery will require not only technological advancements but also targeted interventions to address these inherent limitations and expand the indications for these valuable techniques.

DISCUSSION

The comprehensive review of clinical and surgical approaches in the management of acute pancreatitis offers valuable insights into the complex pathophysiology and evolving treatment paradigms for this potentially life-threatening condition. The detailed elucidation of the disease mechanism—highlighting the role of premature enzyme activation, subsequent autodigestion, and the cascade of inflammatory responses—provides a solid foundation for understanding current therapeutic strategies. The emphasis on early supportive care, particularly fluid resuscitation, underscores its critical importance in preventing progression to systemic inflammatory response syndrome (SIRS) and multiorgan dysfunction syndrome (MODS). Notably, the review underscores the significance of early enteral nutrition, which has been shown to preserve gut integrity and reduce infectious complications, aligning with current best practices. The discussion of surgical intervention—particularly the timing and choice of minimally invasive techniques—reflects a nuanced understanding of balancing benefits and risks, with delayed surgery favoring better tissue demarcation. However, the review also highlights limitations, such as the variability in clinical presentation, challenges in early diagnosis, and the lack of standardized protocols across different institutions, which may influence outcomes. Additionally, while minimally invasive approaches show promise, their applicability remains constrained by technical expertise and case selection criteria, pointing to the necessity for further research to delineate optimal patient profiles. Future investigations should aim to refine diagnostic modalities, establish evidence-based guidelines for intervention timing, and evaluate long-term outcomes of various surgical techniques. The review appropriately advocates for multidisciplinary collaboration to enhance management efficiency and patient recovery. Nonetheless, potential biases stemming from heterogeneity in study designs and the evolving nature of clinical evidence necessitate cautious interpretation of some conclusions. Overall, this review contributes substantially to the understanding of acute pancreatitis management, emphasizing personalized care and early intervention, while also identifying critical areas for ongoing research to improve prognostic outcomes further.

CONCLUSIONS

1. Acute pancreatitis (AP) remains a complex and potentially life-threatening condition requiring a multidisciplinary approach to management. This comprehensive review confirms that significant advances have been made in both clinical and surgical strategies, resulting in improved outcomes, reduced mortality, and a better understanding of the disease’s pathophysiology. The initial management of AP is primarily conservative, with early fluid resuscitation, pain control, and nutritional support being the cornerstones of care. Current evidence strongly supports early enteral nutrition over parenteral feeding, and judicious use of antibiotics only in confirmed infections. Moreover, the role of imaging—particularly contrast-enhanced CT and MRI—has become central in assessing severity and guiding timely interventions.
2. Surgical and interventional approaches have evolved from early open necrosectomy to a more refined, step-up strategy that prioritizes minimally invasive techniques such as percutaneous drainage, endoscopic transluminal necrosectomy, and laparoscopic approaches. This shift has reduced the rates of postoperative complications and mortality, especially in patients with infected pancreatic necrosis. Timing of intervention has also proven crucial; delaying surgery until walled-off necrosis forms—typically after the third or fourth week—has consistently shown better outcomes. However, challenges persist in determining which patients will benefit from surgical versus conservative management, particularly in borderline or severe cases.
3. Despite these advancements, gaps remain in the standardization of care. There is still significant variation in clinical practice across institutions and regions, and a need for clearer, evidence-based algorithms to guide decision-making, particularly in moderate-to-severe cases. Additionally, the long-term consequences of AP—such as exocrine and endocrine insufficiency, recurrent episodes, and diminished quality of life—require more attention in research and follow-up care strategies.

FUTURE DIRECTIONS

Future research should prioritize the identification of reliable early biomarkers and predictive models to stratify disease severity and guide personalized treatment plans. Prospective multicenter trials comparing surgical and minimally invasive interventions—particularly in diverse healthcare settings—are needed to solidify best practices and refine timing protocols. The role of endoscopic ultrasound and emerging interventional endoscopy techniques should also be explored more extensively, especially for patients at high surgical risk.

Furthermore, the development of unified international guidelines and treatment algorithms will be essential to harmonize care and improve global outcomes. Long-term studies evaluating the progression from acute to chronic pancreatitis, as well as the effectiveness of rehabilitative and preventive strategies, will help ensure that AP is managed not just as an acute episode but as part of a broader continuum of pancreatic health.

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