For decades, treatment of severe acute pancreatitis and pancreatic necrosis incorporated aggressive pancreatic debridement via an open necrosectomy.1 The indications for surgical intervention included confirmed or suspected nonviable pancreatic parenchyma, infection within that necrotic collection, or both. This approach often resulted in poor outcomes due to precipitation of a systemic inflammatory response with subsequent organ failure as a result of gross disturbance of an infected necrotic collection.2 In the 1990s, it became apparent that this approach was not required for most patients with sterile pancreatic necrosis.3 However, patients presenting to the hospital with infected pancreatic necrosis—as evidenced by a positive culture from a pancreatic aspirate or gas in the pancreatic phlegmon identified by CT scan—often were promptly taken to the operating room because of the perception that delay in operative intervention with drainage would result in an extremely high mortality rate. Despite advances in critical care, open necrosectomy has both substantial complication rates and mortality rates, in some series as high as 92% and 58%, respectively.4,5
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