Review Staged multidisciplinary step-up management for necrotizing pancreatitis D. W. da Costa 1 , D. Boerma 2 , H. C. van Santvoort 2 , K. D. Horvath 6 , J. Werner 7 , C. R. Carter 8 , T. L. Bollen 3 , H. G. Gooszen 1 , M. G. Besselink 4 and O. J. Bakker 5 1 Department of Operating Theatres and Evidence Based Surgery, Radboud University Medical Centre Nijmegen, Nijmegen, Departments of 2 Surgery and 3 Radiology, St Antonius Hospital, Nieuwegein, 4 Department of Surgery, Academic Medical Centre, Amsterdam, and 5 Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands, 6 Department of Surgery, University of Washington Medical Center, Seattle, Washington, USA, 7 Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany, and 8 Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK Correspondence to: Mr O. J. Bakker, Department of Surgery, HP G04.228, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands (e-mail: o.j.bakker@pancreatitis.nl) Background: Some 15 per cent of all patients with acute pancreatitis develop necrotizing pancreatitis, with potentially significant consequences for both patients and healthcare services. Methods: This review summarizes the latest insights into the surgical and medical management of necrotizing pancreatitis. General management strategies for the treatment of complications are discussed in relation to the stage of the disease. Results: Frequent clinical evaluation of the patient’s condition remains paramount in the first 24–72 h of the disease. Liberal goal-directed fluid resuscitation and early enteral nutrition should be provided. Urgent endoscopic retrograde cholangiopancreatography is indicated when cholangitis is suspected, but it is unclear whether this is appropriate in patients with predicted severe biliary pancreatitis without cholangitis. Antibiotic prophylaxis does not prevent infection of necrosis and antibiotics are not indicated as part of initial management. Bacteriologically confirmed infections should receive targeted antibiotics. With the more conservative approach to necrotizing pancreatitis currently advocated, fine- needle aspiration culture of pancreatic or extrapancreatic necrosis will less often lead to a change in management and is therefore indicated less frequently. Optimal treatment of infected necrotizing pancreatitis consists of a staged multidisciplinary ‘step-up’ approach. The initial step is drainage, either percutaneous or transluminal, followed by surgical or endoscopic transluminal debridement only if needed. Debridement is delayed until the acute necrotic collection has become ‘walled-off’. Conclusion: Outcome following necrotizing pancreatitis has improved substantially in recent years as a result of a shift from early surgical debridement to a staged, minimally invasive, multidisciplinary, step-up approach. Paper accepted 5 September 2013 Published online 22 November 2013 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9346 Introduction In recent decades the incidence of acute pancreatitis has increased globally and the burden on worldwide healthcare services is expected to increase even further 1–6 . Some 85 per cent of patients with acute pancreatitis make a quick and uneventful recovery, requiring little more than analgesia with or without minor supportive measures (for example fluid therapy). However, around 15 per cent develop necrosis of the pancreatic parenchyma or extrapancreatic tissue. Failure of one or more organ systems will ensue in approximately 40 per cent of these patients. Only a minority of patients without pancreatic necrosis develop organ failure, but it can sometimes occur 7 . Both complications are independently associated with prolonged hospital admission, and high morbidity and mortality rates. Should pancreatic or extrapancreatic necrosis become infected, mortality rates increase up to 20 per cent 8 . In necrotizing pancreatitis, the type of complication that may develop is closely related to the time from symptom onset, and specific complications may be managed differently at different time points. Therefore, this review addresses staged multidisciplinary ‘step-up’ strategies  2013 BJS Society Ltd BJS 2014; 101: e65–e79 Published by John Wiley & Sons Ltd