Management of acute necrotizing pancreatitis: Current evidence, controversies and future perspectives

Acute necrotizing pancreatitis affects 10%-20% of patients with acute pancreatitis and carries substantial morbidity and mortality, ranging from 15% in sterile necrosis to 30-40% in infected necrosis.Over the past two decades, management has shifted from early aggressive intervention to a delayed, minimally invasive "step-up" approach, though several aspects remain non-standardized.This narrative review synthesizes evidence from randomized controlled trials, systematic reviews, meta-analyses and current guidelines across diagnosis, supportive care, antibiotics, intervention indications, step-up strategies, minimally invasive and open necrosectomy.Initial management should favor moderate fluid resuscitation, early oral/enteral feeding, and appropriate intensive care unit triage.Antibiotic prophylaxis is unsupported by evidence and therapy should be reserved for confirmed or strongly suspected infected necrosis, guided by clinical/radiological reassessment.When intervention is needed, step-up remains standard of care.Endoscopic and surgical step-up show broadly comparable survival, though not uniformly across anatomical patterns and settings, with endoscopy favoring fistula rates and length of stay.Minimally invasive necrosectomy is associated with lower mortality and fewer complications than open necrosectomy.However, these findings are largely observational and prone to confounding by indication.Based on this evidence, we propose a risk-adapted algorithm separating risk stratification from treatment escalation.