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Disease severity is classified as mild, moderate, or severe, dependent on the presence or degree of concomitant organ failure. Locally, pancreatitis may be complicated by fluid collections, necrosis, infection, and hemorrhage. Infection of necrotizing pancreatitis (NP) is associated with a doubling of mortality risk. The modern management of AP is evolving. Recent data suggest a shift from normal saline to lactated Ringer\u2019s solution, and from aggressive to more judicious volume resuscitation. Similarly, while historical wisdom advocated keeping patients nothing by mouth to \u2018rest the pancreas\u2019, recent data convincingly show fewer complications and reduced mortality with early enteral nutrition, when tolerated by the patient. The use of antibiotics in NP is controversial. Current recommendations suggest reserving antibiotics for cases with highly suspected or confirmed infected necrosis, as well as in patients with biliary pancreatitis complicated by acute cholecystitis or cholangitis. Regarding the management of local complications, control of acute hemorrhage can be attained either endovascularly or via laparotomy. Abdominal compartment syndrome is associated with a mortality risk of 50%\u201375%. Routine monitoring of intra-abdominal pressure is recommended in patients at high risk. Pancreatic pseudocysts require intervention in symptomatic patients or those with infection or other complications. Endoscopic transmural drainage may be considered as the first step when technically feasible. Necrotizing pancreatitis without suspicion of infection is often managed medically, while the delay, drain, debride approach remains the standard of care for the vast majority of infected pancreatic necrosis. Robotic surgery, in appropriately selected patients, allows for a one-step approach, and merits further study to explore its initially promising results.<\/jats:p>","DOI":"10.1136\/tsaco-2025-001798","type":"journal-article","created":{"date-parts":[[2025,4,14]],"date-time":"2025-04-14T15:00:21Z","timestamp":1744642821000},"page":"e001798","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":6,"title":["Managing complicated pancreatitis with more knowledge and a bigger toolbox!"],"prefix":"10.1136","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6476-9332","authenticated-orcid":false,"given":"Chris","family":"Cribari","sequence":"first","affiliation":[{"name":"Trauma and Acute Care Surgery, Medical Center of the Rockies, Loveland, Colorado, USA"},{"name":"Trauma and Acute Care Surgery, University of Colorado Health, Loveland, Colorado, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joshua","family":"Tierney","sequence":"additional","affiliation":[{"name":"UCHealth Medical Group, Loveland, Colorado, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4749-969X","authenticated-orcid":false,"given":"Lacey","family":"LaGrone","sequence":"additional","affiliation":[{"name":"Trauma and Acute Care Surgery, Medical Center of the Rockies, Loveland, Colorado, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,4,14]]},"reference":[{"key":"2025081710555468000_10.Suppl_1.e001798.1","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2021.09.043"},{"key":"2025081710555468000_10.Suppl_1.e001798.2","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2021.10.017"},{"key":"2025081710555468000_10.Suppl_1.e001798.3","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(20)31310-6"},{"key":"2025081710555468000_10.Suppl_1.e001798.4","doi-asserted-by":"crossref","first-page":"2902","DOI":"10.3748\/wjg.v26.i22.2902","article-title":"Ever-increasing diversity of drug-induced pancreatitis","volume":"26","author":"Weissman","year":"2020","journal-title":"World J Gastroenterol"},{"key":"2025081710555468000_10.Suppl_1.e001798.5","doi-asserted-by":"publisher","DOI":"10.1136\/gutjnl-2012-302779"},{"key":"2025081710555468000_10.Suppl_1.e001798.6","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2018.12.041"},{"key":"2025081710555468000_10.Suppl_1.e001798.7","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2010.06.010"},{"key":"2025081710555468000_10.Suppl_1.e001798.8","doi-asserted-by":"publisher","DOI":"10.1136\/gutjnl-2012-303724"},{"key":"2025081710555468000_10.Suppl_1.e001798.9","first-page":"69","article-title":"Prognostic signs and the role of operative management in acute pancreatitis","volume":"139","author":"Ranson","year":"1974","journal-title":"Surg Gynecol Obstet"},{"key":"2025081710555468000_10.Suppl_1.e001798.10","first-page":"443","article-title":"Objective early identification of severe acute pancreatitis","volume":"61","author":"Ranson","year":"1974","journal-title":"Am J Gastroenterol"},{"key":"2025081710555468000_10.Suppl_1.e001798.11","doi-asserted-by":"publisher","DOI":"10.1148\/radiology.174.2.2296641"},{"key":"2025081710555468000_10.Suppl_1.e001798.12","doi-asserted-by":"crossref","first-page":"482","DOI":"10.7326\/M16-0650","article-title":"Prediction Models of Mortality in Acute Pancreatitis in Adults: A Systematic Review","volume":"165","author":"Di","year":"2016","journal-title":"Ann Intern Med"},{"key":"2025081710555468000_10.Suppl_1.e001798.13","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0130412","article-title":"The Value of BISAP Score for Predicting Mortality and Severity in Acute Pancreatitis: A Systematic Review and Meta-Analysis","volume":"10","author":"Gao","year":"2015","journal-title":"PLoS One"},{"key":"2025081710555468000_10.Suppl_1.e001798.14","doi-asserted-by":"crossref","unstructured":"Gurusamy KS , Debray TPA , Rompianesi G . 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