Perioperative factors determine outcome after surgery for severe acute pancreatitis

Acute Pancreatitis and Acute Recurrent Pancreatitis in Children: Imaging Findings and Outcomes

OBJECTIVE

The prevalence of acute pancreatitis and acute recurrent pancreatitis in children has increased over the years, and there are limited data about imaging findings. This study aimed to reveal the imaging findings of acute pancreatitis and acute recurrent pancreatitis in children at a tertiary care hospital.

MATERIALS AND METHODS

The patients with acute pancreatitis and acute recurrent pancreatitis diagnosed between January 2007 and December 2018 were included. Demographic and clinical features, follow-up period, and interventions were noted. Imaging features were evaluated for pancreatic enlargement, peripancreatic fluid, and biliary ducts for initial examination and pancreas parenchymal necrosis, peripancreatic collection, walled-off necrosis, pseudocyst, parenchymal atrophy, and biliary ductal dilatation for follow-up.

RESULTS

The study included 74 patients with a mean age of 9 ± 4.9 years. The most common causes of acute pancreatitis and acute recurrent pancreatitis were biliary tract anomalies (n = 21), biliary ductal stones (n = 9), and cystic fibrosis (n = 8). Findings consistent with acute pancreatitis were determined by ultrasound in 40.5% (n = 30/74), whereas by magnetic resonance imaging in 60% (n = 39/65). Forty-one percent of the patients (n = 16) with positive magnetic resonance imaging findings did not show any findings on ultrasound. Acute recurrent pancreatitis was seen in 32 patients (43.2%). Follow-up imaging was performed in 55 patients (74.3%) between 2 months and 11 years. At follow-up, 8 patients had peripancreatic collections (6 walled-off necrosis and 2 pseudocysts).

CONCLUSION

Recognizing the imaging findings of acute pancreatitis and its complications is crucial. Magnetic resonance imaging should be preferred as a second option following ultrasound, with the advantages of biliary ductal system delineation and better characterization of complications.

The role of endoscopic therapy in the minimally invasive management of pancreatic necrosis

Pancreatic necrosis is among the most frequently encountered local complications of acute pancreatitis and associates with severe disease. Infected pancreatic necrosis further enhances the risk for morbidity and mortality. Pancreatic fluid collections that result from pancreatic necrosis evolve from acute necrotic collections to walled off necrosis and are defined by their distinct characteristics on cross sectional imaging. A variety of interventions spanning multiple disciplines are available for the drainage and debridement of pancreatic necrosis. Prospective, randomized trials have identified management strategies that incorporate minimally invasive interventions as having the best outcomes for patients with symptomatic pancreatic necrosis. The scientific literature has confidently positioned endoscopic drainage and necrosectomy among the most effective interventions for patients with symptomatic walled off necrosis. Innovations such as the use of metallic stents, chemical debridement and multiple modalities for drainage of pancreatic necrosis show promise in improving outcomes for patients managed with endoscopic interventions.

Minimally invasive drainage in critically ill patients with severe necrotizing pancreatitis is associated with better outcomes: an observational study

Background

Infected pancreatic necrosis, which occurs in about 40% of patients admitted for acute necrotizing pancreatitis, requires combined antibiotic therapy and local drainage. Since 2010, drainage by open surgical necrosectomy has been increasingly replaced by less invasive methods such as percutaneous radiological drainage, endoscopic necrosectomy, and laparoscopic surgery, which proved effective in small randomized controlled trials in highly selected patients. Few studies have evaluated minimally invasive drainage methods used under the conditions of everyday hospital practice. The aim of this study was to determine whether, compared with conventional open surgery, minimally invasive drainage was associated with improved outcomes of critically ill patients with infection complicating acute necrotizing pancreatitis.

Methods

A single-center observational study was conducted in patients admitted to the intensive care unit for severe acute necrotizing pancreatitis to compare the characteristics, drainage techniques, and outcomes of the 62 patients managed between September 2006 and December 2010, chiefly with conventional open surgery, and of the 81 patients managed between January 2011 and August 2015 after the introduction of a minimally invasive drainage protocol.

Results

Surgical necrosectomy was more common in the early period (74% versus 41%; P <0.001), and use of minimally invasive drainage increased between the early and late periods (19% and 52%, respectively; P <0.001). The numbers of ventilator-free days and catecholamine-free days by day 30 were higher during the later period. The proportions of patients discharged from intensive care within the first 30 days and from the hospital within the first 90 days were higher during the second period. Hospital mortality was not significantly different between the early and late periods (19% and 22%, respectively).

Conclusion

In our study, the implementation of a minimally invasive drainage protocol in patients with infected pancreatic necrosis was associated with shorter times spent with organ dysfunction, in the intensive care unit, and in the hospital. Mortality was not significantly different. These results should be interpreted bearing in mind the limitations inherent in the before-after study design.

WITHDRAWN: Stilamin inhibits intestinal and pancreatic injury in rats with severe acute pancreatitis by down-regulating LCN2 expression

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Infection increases mortality in necrotizing pancreatitis: A systematic review and meta-analysis

OBJECTIVES

To assess the influence of infection on mortality in necrotizing pancreatitis.

METHODS

Eligible prospective and retrospective studies were identified through manual and electronic searches (August 2015). The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). Meta-analyses were performed with subgroup, sensitivity, and meta-regression analyses to evaluate sources of heterogeneity.

RESULTS

We included 71 studies (n = 6970 patients). Thirty-seven (52%) studies used a prospective design and 25 scored ≥5 points on the NOS suggesting a low risk of bias. Forty studies were descriptive and 31 studies evaluated invasive interventions. In total, 801 of 2842 patients (28%) with infected necroses and 537 of 4128 patients (13%) with sterile necroses died with an odds ratio [OR] of 2.57 (95% confidence interval [CI], 2.00-3.31) based on all studies and 2.02 (95%CI, 1.61-2.53) in the studies with the lowest bias risk. The OR for prospective studies was 2.96 (95%CI, 2.51-3.50). In sensitivity analyses excluding studies evaluating invasive interventions, the OR was 3.30 (95%CI, 2.81-3.88). Patients with infected necrosis and organ failure had a mortality of 35.2% while concomitant sterile necrosis and organ failure was associated with a mortality of 19.8%. If the patients had infected necrosis without organ failure the mortality was 1.4%.

CONCLUSIONS

Patients with necrotizing pancreatitis are more than twice as likely to die if the necrosis becomes infected. Both organ failure and infected necrosis increase mortality in necrotizing pancreatitis.

Acute Pancreatitis: Revised Atlanta Classification and the Role of Cross-Sectional Imaging

OBJECTIVE

The 2012 revision of the Atlanta Classification emphasizes accurate characterization of collections that complicate acute pancreatitis: acute peripancreatic fluid collections, pseudocysts, acute necrotic collections, and walled-off necroses. As a result, the role of imaging in the management of acute pancreatitis has substantially increased.

CONCLUSION

This article reviews the imaging findings associated with acute pancreatitis and its complications on cross-sectional imaging and discusses the role of imaging in light of this revision.

Early-phase peritoneal drainage and lavage in a rat model of severe acute pancreatitis

PURPOSE

To evaluate the effects of early-phase drainage on the survival rates and pancreatic pathological changes associated with severe acute pancreatitis (SAP) in a rat model.

METHODS

Sprague-Dawley rats were divided into the following groups: SAP model (control), early drainage and delayed drainage. The 24-h survival rates were compared among the groups. In addition, the serum and ascites concentrations of interleukin (IL)-1β, IL-6, IL-8, IL-10 and tumor necrosis factor (TNF)-α were measured, and pancreatic pathological changes were observed.

RESULTS

The survival rate significantly improved in the early drainage group. Compared with that observed in the control group, the serum TNF-α and IL-8 concentrations in the early drainage group decreased, while the serum IL-10 levels increased, and the ascites concentrations of IL-1β, IL-6, IL-8 and TNF-α decreased, while that of IL-10 increased significantly. In the delayed drainage group, only the ascites concentrations of TNF-α decreased. Meanwhile, the pancreatic pathological changes at 3, 6 and 24 h worsened in the early drainage group; however, the pancreatic lesions in the early drainage group were less mild than those seen in the control group.

CONCLUSIONS

Rebalancing the cytokine levels in ascites after early drainage may be a key factor for enhancing the survival rate in rats.

The role of organ failure and infection in necrotizing pancreatitis: a prospective study

OBJECTIVE

To clarify the roles of organ failure and infection in the outcome of necrotizing pancreatitis.

BACKGROUND

Results of previous cohort studies that focused on the roles of infection and organ failure in acute pancreatitis are controversial.

METHODS

In this study, we collected the medical records of 447 patients with necrotizing pancreatitis from January 2009 to June 2012. Data associated with organ failure and infection were analyzed.

RESULTS

The overall mortality rate was 13% (58/447). Intervention was performed in 223 of 447 patients. Among these 223 patients, 134 were confirmed to be with infected necrosis by a positive culture. The mortality rate was 15% (13/89) in the sterile necrosis group and 18% (24/134) in the infected necrosis group (P = 0.52). A multivariate analysis of death predictors indicated that bacteremia (odds ratio [OR] = 2.76, 95% confidence interval [CI], 1.23-5.46, P < 0.001), age (OR = 1.07, 95% CI, 1.03-1.11, P < 0.001), American Society of Anesthesiologists class (OR = 3.56, 95% CI, 1.65-7.18, P = 0.001), persistent organ failure in the first week (OR = 16.72, 95% CI, 7.04-32.56, P < 0.001), and pancreatic necrosis (OR = 1.73, 95% CI, 1.14-2.98, P = 0.008) were significant factors.

CONCLUSIONS

Among patients with necrotizing pancreatitis, the effects of organ failure on mortality are more critical than those of infection. Bacteremia, age, American Society of Anesthesiologists class, persistent organ failure in the first week, and pancreatic necrosis were identified as the predictors of mortality.

Evolution and results of the surgical management of 143 cases of severe acute pancreatitis in a referral centre

INTRODUCTION

Surgery is the accepted treatment for infected acute pancreatitis, although mortality remains high. As an alternative, a staged management has been proposed to improve results. Initial percutaneous drainage could allow surgery to be postponed, and improve postoperative results. Few centres in Spain have published their results of surgery for acute pancreatitis.

OBJECTIVE

To review the results obtained after surgical treatment of acute pancreatitis during a period of 12 years, focusing on postoperative mortality.

MATERIAL AND METHODS

We have reviewed the experience in the surgical treatment of severe acute pancreatitis (SAP) at Bellvitge University Hospital from 1999 to 2011. To analyse the results, 2 periods were considered, before and after 2005. A descriptive and analytical study of risk factors for postoperative mortality was performed

RESULTS

A total of 143 patients were operated on for SAP, and necrosectomy or debridement of pancreatic and/or peripancreatic necrosis was performed, or exploratory laparotomy in cases of massive intestinal ischemia. Postoperative mortality was 25%. Risk factors were advanced age (over 65 years), the presence of organ failure, sterility of the intraoperative simple, and early surgery (< 7 days). The only risk factor for mortality in the multivariant analysis was the time from the start of symptoms to surgery of<7 days; furthermore, 50% of these patients presented infection in one of the intraoperative cultures.

CONCLUSIONS

Pancreatic infection can appear at any moment in the evolution of the disease, even in early stages. Surgery for SAP has a high mortality rate, and its delay is a factor to be considered in order to improve results.

Acute kidney injury following acute pancreatitis: A review

BACKROUND. Acute kidney injury (AKI) is a common serious complication of severe acute pancreatitis (SAP) and an important marker of morbidity and mortality in critically ill septic patients. AKI due to severe acute pancreatitis can be the result of hypoxemia, release of pancreatic amylase from the injured pancreas with impairment of renal microcirculation, decrease in renal perfusion pressure due to abdominal compartment syndrome, intraabdominal hypertension or hypovolemia. Endotoxins and reactive oxygen species (ROS) also play an important role in the pathophysiology of SAP and AKI. Knowledge of the pathophysiology and diagnosis of AKI following SAP might improve the therapeutic outcome of critically ill patients.

METHODS AND RESULTS

An overview of the pathophysiology, diagnosis and potential treatment options based on a literature search of clinical human and experimental studies from 1987 to 2013.

CONCLUSIONS

Early recognition of AKI and SAP in order to prevent severe complication like septic shock, intraabdominal hypertension or abdominal compartment syndrome leading to multiple organ dysfunction syndrome is a crucial tool of therapeutic measures in intensive care.

Scoring of human acute pancreatitis: state of the art

BACKGROUND

Acute pancreatitis remains as one of the most difficult and challenging digestive disorder to predict in terms of clinical course and outcome. Every case has an individual course and therefore acute pancreatitis remains challenging and fascinating. Due to this variability, many different scoring systems have evolved during the last decades. Every scoring system has advantages and disadvantages. Not every scoring system is capable of assessing the clinical time course of the disease, some are only suitable for the time of initial presentation.

AIM

This paper will give an overview on the development of different widely used scoring systems and their performance in assessing severity and prognosis of acute pancreatitis.

CONCLUSION

Severity assessment means objective quantification of overall severity of illness. Early and reliable stratification of severity is required to decide best treatment of the individual patient, preparation for possible evolving complications or for referral to specialist centers. No single scoring system is able to cover the entire range of problems associated with treatment and assessment of acute pancreatitis. In our clinical experience, we recommend hematocrit upon admission, daily sequential organ failure assessment score and procalcitonin, C-reactive protein on day 3 and CT severity index beyond the first week. These scoring tools together with close clinical follow-up of the patient ultimately lead to an optimized treatment of this challenging disease.

An update on minimally invasive therapies for pancreatic necrosis

Pancreatic necrosis is a local complication of severe acute pancreatitis associated with multiple organ dysfunction, infection and increased mortality. While surgery is the mainstay for invasive management, studies have demonstrated that delaying necrosectomy translates to improved patient outcomes. Minimally invasive therapies have been described both for early and late management of necrotic pancreatic collections and fall into three broad categories: endoscopic, radiology assisted percutaneous drainage and laparoscopic or retroperitoneal surgical techniques. Such interventions may serve as temporizing measures delaying necrosectomy, but more importantly, as best demonstrated in recent randomized controlled trials, can serve as alternative approaches resulting in improved patient outcomes. Access to these techniques is based on their availability at expert centers. Minimally invasive therapies have increased in popularity, with a general consensus among experts being that reduced complications and mortality rates are realized by approaches other than open necrosectomy. However, additional well-designed, randomized trials are needed.

Correlates of morbidity and mortality in severe necrotizing pancreatitis

Acute severe pancreatitis is associated with a high morbidity and mortality and frequently is accompanied by underlying pancreatic parenchymal necrosis. Patients with pancreatic necrosis must be identified, because the morbidity and mortality rate in this subgroup is much higher. Our objective was to compare the clinical outcomes of these patients based on the degree of pancreatic necrosis. A total of 35 patients were noted to have pancreatic necrosis. These were divided into 2 groups based on extent of necrosis: group A had less than 50% necrosis and group B had more than 50% necrosis. The rate of mortality (5% versus 40%) was significantly higher in group B. The rate of organ dysfunction also rose along with the rates of other morbidities and variables that were related to a patient's hospital stay. Only APACHE II significantly correlated with the degree of necrosis, wherein the chances of substantial necrosis rose by 20% with each unit increase of APACHE II score. APACHE II Score could be employed and studied further prospectively to help identify patients with pancreatic necrosis.

Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis

BACKGROUND & AIMS

There is no consistency between the individual studies in the literature on whether organ failure (OF) or infected pancreatic necrosis (IPN) is the main determinant of severity in acute pancreatitis. We aimed to statistically aggregate the available data and determine the pooled influence of OF and IPN on mortality in patients with acute pancreatitis.

METHODS

The search for relevant observational studies was undertaken in the MEDLINE, EMBASE, and Scopus electronic databases, as well as in the proceedings of major gastroenterology meetings. The summary estimates are presented as relative risk (RR) and 95% confidence interval (CI).

RESULTS

Fourteen studies comprising 1478 patients with acute pancreatitis were meta-analyzed. A total of 600 patients developed OF and 179 of them died (mortality, 30%); 314 patients developed IPN and 102 of them died (mortality, 32%). In a stratified analysis, patients with OF and IPN had a significantly higher risk of death in comparison with patients with OF and no IPN (RR = 1.94; 95% CI: 1.32-2.85; P = .0007) and in comparison with patients with IPN and no OF (RR = 2.65; 95% CI: 1.30-5.40; P = .0007).

CONCLUSIONS

In patients with acute pancreatitis, the absolute influence of OF and IPN on mortality is comparable and thus the presence of either indicates severe disease. The relative risk of mortality doubles when OF and IPN are both present and indicates extremely severe disease or critical acute pancreatitis.

Therapeutic intervention and surgery of acute pancreatitis

The clinical course of acute pancreatitis varies from mild to severe. Assessment of severity and etiology of acute pancreatitis is important to determine the strategy of management for acute pancreatitis. Acute pancreatitis is classified according to its morphology into edematous pancreatitis and necrotizing pancreatitis. Edematous pancreatitis accounts for 80-90% of acute pancreatitis and remission can be achieved in most of the patients without receiving any special treatment. Necrotizing pancreatitis occupies 10-20% of acute pancreatitis and the mortality rate is reported to be 14-25%. The mortality rate is particularly high (34-40%) for infected pancreatic necrosis that is accompanied by bacterial infection in the necrotic tissue of the pancreas (Widdison and Karanjia in Br J Surg 80:148-154, 1993; Ogawa et al. in Research of the actual situations of acute pancreatitis. Research Group for Specific Retractable Diseases, Specific Disease Measure Research Work Sponsored by Ministry of Health, Labour, and Welfare. Heisei 12 Research Report, pp 17-33, 2001). On the other hand, the mortality rate is reported to be 0-11% for sterile pancreatic necrosis which is not accompanied by bacterial infection (Ogawa et al. 2001; Bradely and Allen in Am J Surg 161:19-24, 1991; Rattner et al. in Am J Surg 163:105-109, 1992). The Japanese (JPN) Guidelines were designed to provide recommendations regarding the management of acute pancreatitis in patients having a variety of clinical characteristics. This article describes the guidelines for the surgical management and interventional therapy of acute pancreatitis by incorporating the latest evidence for the management of acute pancreatitis in the Japanese-language version of JPN guidelines 2010. Eleven clinical questions (CQ) are proposed: (1) worsening clinical manifestations and hematological data, positive blood bacteria culture test, positive blood endotoxin test, and the presence of gas bubbles in and around the pancreas on CT scan are indirect findings of infected pancreatic necrosis; (2) bacteriological examination by fine needle aspiration is useful for making a definitive diagnosis of infected pancreatic necrosis; (3) conservative treatment should be performed in sterile pancreatic necrosis; (4) infected pancreatic necrosis is an indication for interventional therapy. However, conservative treatment by antibiotic administration is also available in patients who are in stable general condition; (5) early surgery for necrotizing pancreatitis is not recommended, and it should be delayed as long as possible; (6) necrosectomy is recommended as a surgical procedure for infected necrosis; (7) after necrosectomy, a long-term follow-up paying attention to pancreatic function and complications including the stricture of the bile duct and the pancreatic duct is necessary; (8) drainage including percutaneous, endoscopic and surgical procedure should be performed for pancreatic abscess; (9) if the clinical findings of pancreatic abscess are not improved by percutaneous or endoscopic drainage, surgical drainage should be performed; (10) interventional treatment should be performed for pancreatic pseudocysts that give rise to symptoms, accompany complications or increase the diameter of cysts and (11) percutaneous drainage, endoscopic drainage or surgical procedures are selected in accordance with the conditions of individual cases.

Minimally invasive necrosectomy for infected necrotizing pancreatitis

OBJECTIVES

Infected necrotizing pancreatitis represents a serious and therapeutically challenging complication. Percutaneous drainage of infected pancreatic necrosis is often unsuccessful. Alternatively, open necrosectomies are associated with high morbidity. Recently, minimally invasive necrosectomy techniques have been tried with satisfying results; however, they frequently necessitate multiple sessions for definitive necrosectomy. To evaluate results of single large-port laparoscopic necrosectomy for proven infected necrotizing pancreatitis.

METHODS

Eight patients presenting proven infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological drainage were prospectively offered minimally invasive necrosectomy. Laparoscopic necrosectomy were performed using a single large port placed along the drain tract directly into the infected necrosis. In all patients, drainage was placed during laparoscopic necrosectomy for continuous postoperative lavage.

RESULTS

No perioperative complications were recorded with a median operative time of 87 +/- 42 minutes. No blood transfusions were needed. No surgical postoperative morbidity and mortality were recorded. In all cases, except for one patient with multiple abscesses, only one session of necrosectomy was sufficient to completely clear the necrotic abscess. Laparoscopic necrosectomy was successful in all patients, and none required complementary surgical or radiological treatment.

CONCLUSIONS

Minimally invasive necrosectomy has been safe and highly efficient through single large-port laparoscopy for infected pancreatic necrosis in our series of patients. Minimally invasive necrosectomy is a promising technique for infected necrotizing pancreatitis and should be regarded as a valid therapeutic option for necrotizing pancreatitis.

Current pharmacotherapeutic recommendations for acute pancreatitis

Disease severity in patients with acute pancreatitis varies from mild disease with minimal morbidity to severe disease in which a whole spectrum of local and systemic complications may occur. Infectious complications frequently arise, and pancreatic necrosis in particular is an important risk factor for mortality. Several strategies have been investigated to stop the progression of organ dysfunction, targeting different steps in the pathogenesis, but none of these have proved beneficial. In recent years, the widespread use of prophylactic antibiotics has also been in question, as one blinded study could not demonstrate an advantage. Better risk stratification methods should improve the design of future trials, so that only patients with a high probability of complications can be studied.

Candida peritonitis

PURPOSE OF REVIEW

The review highlights current insights in the epidemiology, diagnosis and therapy of Candida peritonitis, focusing on complicated secondary and tertiary peritonitis.

RECENT FINDINGS

Candida peritonitis is still associated with poor prognosis. Antifungal prophylaxis is therefore recommended in patients with an overt risk profile for invasive candidiasis (immunodeficiency and prior antibiotic exposure). The clinical and microbiological diagnosis of Candida peritonitis remains problematic. It is still unclear which peritonitis patients may benefit from antifungal treatment. Antifungal therapy can be suggested in critically ill patients with nosocomial peritonitis where Candida is diagnosed based on perioperatively sampled peritoneal fluid. Patients with prior exposure to fluconazole are at risk for Candida nonalbicans spp. involvement with possible reduced susceptibility.

SUMMARY

The main challenge in Candida peritonitis remains the interpretation of Candida cultured from the peritoneal cavity. Future research should focus on more conclusive diagnosis and on factors potentially confounding outcome, such as site of the perforation and failure of surgical source control. While awaiting progress to discriminate Candida colonization from invasive infection, antifungal therapy is recommended in high-risk critically ill surgical patients. Rapid detection of Candida might be beneficial in this regard. Besides antifungal therapy, adequate source control is of key importance.

Intra-abdominal hypertension in patients with severe acute pancreatitis

Introduction

Abdominal compartment syndrome has been described in patients with severe acute pancreatitis, but its clinical impact remains unclear. We therefore studied patient factors associated with the development of intra-abdominal hypertension (IAH), the incidence of organ failure associated with IAH, and the effect on outcome in patients with severe acute pancreatitis (SAP).

Methods

We studied all patients admitted to the intensive care unit (ICU) because of SAP in a 4 year period. The incidence of IAH (defined as intra-abdominal pressure ≥ 15 mmHg) was recorded. The occurrence of organ dysfunction during ICU stay was recorded, as was the length of stay in the ICU and outcome.

Results

The analysis included 44 patients, and IAP measurements were obtained from 27 patients. IAH was found in 21 patients (78%). The maximum IAP in these patients averaged 27 mmHg. APACHE II and Ranson scores on admission were higher in patients who developed IAH. The incidence of organ dysfunction was high in patients with IAH: respiratory failure 95%, cardiovascular failure 91%, and renal failure 86%. Mortality in the patients with IAH was not significantly higher compared to patients without IAH (38% versus 16%, p = 0.63), but patients with IAH stayed significantly longer in the ICU and in the hospital. Four patients underwent abdominal decompression because of abdominal compartment syndrome, three of whom died in the early postoperative course.

Conclusion

IAH is a frequent finding in patients admitted to the ICU because of SAP, and is associated with a high occurrence rate of organ dysfunction. Mortality is high in patients with IAH, and because the direct causal relationship between IAH and organ dysfunction is not proven in patients with SAP, surgical decompression should not routinely be performed.

Risk management in patients with severe acute pancreatitis

Primary or secondary infection of necrotized areas by enteral bacteria is considered a primary cause of mortality in patients with severe acute pancreatitis (SAP). Indeed, 20–30% of patients die during the course of the disease from multiple organ dysfunction after infection. This is why strategies such as antibiotic prophylaxis and early surgical intervention are appealing, but the controlled data that support these measures are insufficient. On the other hand, environmental risk factors (e.g. smoking, alcohol) and genetic predisposition have been identified; together, these led to SAP being considered a 'multifactorial' disease. However, this description does not help the intensivist to assess risk in the individual patient. A number of prognostic factors in SAP have been identified, and different scoring systems have been developed that include therapy-associated and patient-related factors. Nevertheless, at present no prognostic model is available that takes into account all of these predictors. Moreover, despite several attempts to create guideline-based strategies, SAP is still characterized by rapidly progressive multiple organ failure and high mortality, and both surgical and conservative therapies yield poor outcomes. This brief commentary highlights the most recent developments in risk management for patients with SAP.