Table 3. The key recommendations and the best evidence for surgical indications of severe acute pancreatitis in including guidelines.
| The key recommendations | The best evidence to support the recommendations at present | Strength of recommendation* | Quality of evidence* | WS (3) | AI (4) | Yo (5) | Gr (6) | AG (7) | Li (8) | ES (9) |
|---|---|---|---|---|---|---|---|---|---|---|
| 1. Indication for emergent ERCP | ||||||||||
| Acute gallstone pancreatitis with cholangitis or common bile duct obstruction | A systematic review of seven randomized controlled trials (RCT) comprising 757 participants (13) | A | 1a | ● | ● | ● | ● | ● | ● | ● |
| A meta-analysis of eleven RCTs consisting of 1,314 patients (14) | ||||||||||
| 2. Indication for percutaneous/endoscopic drainage | ||||||||||
| Clinical deterioration with signs or strong suspicion of infected necrotizing pancreatitis | A systematic review including 10 retrospective series and one RCT with a total of 384 patients (15) | C | 4 | ● | ● | ● | ● | – | ● | ● |
| 3. Indication for surgical intervention | ||||||||||
| Abdominal compartment syndrome (ACS): IAP >20 mmHg accompanied by new organ disorder/failure | A systematic review including 7 retrospective or prospective cohort studies with a total of 271 patients (ACS =103) (16) | C | 4 | ● | ● | ● | – | – | ● | ● |
| Acute on-going bleeding when endovascular approach is unsuccessful or bowel ischaemia | A retrospective case series analysis including 9 patients with bleeding (17) | C | 4 | ● | ● | – | – | – | – | – |
| Acute necrotizing cholecystitis | A systematic review including 8 cohort studies (n=948) and 1 RCT (n=50) (18) | B | 3a | ● | – | – | ● | – | ● | – |
| Infected pancreatic necrosis | Retrospective analysis of 167 patients with necrotizing pancreatitis (19) | C | 4 | ● | ● | ● | ● | – | – | ● |
| 4. Timing of surgery | ||||||||||
| Postponing surgical interventions for more than 4 weeks after the onset of the disease | A systematic review pooling the timing of operative intervention (30 days) according 4 studies (20) | B | 3a | ● | ● | ● | ● | – | ● | ● |
| 5. Surgical strategy | ||||||||||
| In infected pancreatic necrosis, percutaneous drainage as the first line of treatment (step-up approach) | A study combining original and newly collected data from 15 published and unpublished patient cohorts on pancreatic necrosectomy for necrotizing pancreatitis (21) | B | 2a | ● | ● | ● | ● | – | ● | ● |
| In selected cases with walled-off necrosis and in patients with disconnected pancreatic duct, a single stage surgical trans-gastric necrosectomy is an option | A retrospective case series study including 178 patients with walled-off pancreatic necrosis (22) | C | 4 | ● | ● | ● | ● | – | ● | ● |
| 6. Timing of cholecystectomy | ||||||||||
| Laparoscopic cholecystectomy during index admission is recommended in mild acute gallstone pancreatitis | A Meta-analysis of randomized clinical trials including 5 RCTs of 629 patients (23) | A | 1a | ● | – | ● | ● | ● | ● | – |
| In acute gallstone pancreatitis with peripancreatic fluid collections, cholecystectomy should be deferred until fluid collections resolve or stabilize and acute inflammation ceases | A retrospective study including 187 patients with moderate to severe acute pancreatitis (24) | C | 4 | ● | – | – | ● | – | ● | – |
| 7. Open abdomen | ||||||||||
| In patients with severe acute pancreatitis unresponsive to conservative management of intra-abdominal hypertension (IAH)/ACS, surgical decompression and use of open abdomen are effective in treating the abdominal compartment syndrome | A retrospective study including 74 patients with acute pancreatitis (25) | C | 4 | ● | ● | ● | – | – | ● | ● |
● indicates being recommended definitely; ● indicates being mentioned; – indicates being not mentioned. *, strength of recommendation and quality of evidence were assessed by using OCEBM standard. OCEBM, Oxford Centre for Evidence-Based Medicine.