Until this date, the cornerstone of treatment in patients with severe acute pancreati­tis is supportive care. Several studies have been conducted in the early phase of acute pancreatitis in order to prevent severe disease progression and reduce compli­cations [11–14]. Unfortunately, these studies showed no improvement in clinical outcomes and the right treatment in the early phase of acute pancreatitis for reduc­tion of organ failure and mortality is still lacking. An option for treatment may be modication of the immune response in the early phase of predicted severe acute pancreatitis through the administration of early intravenous omega-3 fatty acids in patients. Omega-3 fatty acids replace arachidonic acids (omega-6) in the inamma­tory mediator production cascade [15]. In addition, omega-3 fatty acids provide increased production of resolvins which improve normalization of inammatory tissue [16]. These actions of omega-3 fatty acids could potentially lead to an effec­tive response of the immune system. A meta-analysis [17] was performed to inves­tigate the safety and efcacy of omega-3in patients with acute pancreatitis and sepsis. The meta-analysis demonstrated a lower incidence of mortality after omega-3 fatty acids infusion. Furthermore, a recent single-center randomized controlled trial [18] demonstrated decreased CRP levels and decreased onset of new organ failure in patients with predicted severe pancreatitis after administration of omega-3 fatty acids. To provide solid evidence on the true potential of omega-3 fatty acids, the PLANCTON multicenter randomized trial is currently in progress in the Netherlands in patients with predicted severe acute pancreatitis.

According to current guidelines, ERCP is not recommended for mild biliary pancre­atitis without cholangitis or predicted severe biliary pancreatitis without cholangitis and no presence of common bile duct obstruction [1, 51]. Urgent ERCP (within 24h of admission) might be favorable in patients with persistent cholestasis and is cur­rently only indicated in patients with biliary pancreatitis and concurrent acute chol­angitis [1, 52, 53]. It was hypothesized that ERCP combined with papillotomy might also reduce the severity of biliary pancreatitis by reducing pressure in the common bile duct [54]. The multicenter randomized APEC trial [55] demonstrated that routine urgent ERCP with biliary papillotomy did not lower rates of mortality or major complications in patients with predicted severe acute biliary pancreatitis when compared to conservative treatment (38 vs. 44%). It therefore appears that only patients with acute biliary pancreatitis and concurrent cholangitis benet from ERCP, especially in the rst 24h of admission.