From the Guidelines
The management of acute necrotizing pancreatitis requires a multidisciplinary approach focusing on supportive care, infection prevention, and selective intervention, with the most recent and highest quality study 1 suggesting that aggressive intravenous hydration may not be beneficial and could potentially increase the risk of fluid overload and mortality. Initial management includes aggressive fluid resuscitation with crystalloids, pain control with opioid analgesics, and nutritional support.
- Early enteral nutrition should be initiated within 48-72 hours via nasojejunal or nasogastric tube to maintain gut barrier function and reduce infectious complications, as supported by the ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1.
- Prophylactic antibiotics are not routinely recommended unless there is confirmed infection, as stated in the American Gastroenterological Association institute guideline on initial management of acute pancreatitis 1.
- For infected necrosis, broad-spectrum antibiotics such as carbapenems (meropenem 1g IV q8h) or combinations like piperacillin-tazobactam (4.5g IV q8h) should be administered.
- Intervention for necrotic collections should be delayed until at least 4 weeks after onset to allow for walling-off, unless the patient deteriorates, as recommended in the 2019 WSES guidelines for the management of severe acute pancreatitis 1.
- The step-up approach is preferred, starting with percutaneous drainage followed by minimally invasive necrosectomy if necessary, rather than immediate open surgical debridement.
- Intensive care monitoring is essential for patients with organ failure, with attention to respiratory and cardiovascular support, to minimize complications and address the pathophysiological processes of pancreatic necrosis, including inflammation, infection, and organ dysfunction.
From the Research
Management Approach for Acute Necrotizing Pancreatitis
The management of acute necrotizing pancreatitis involves a multidisciplinary approach, including medical treatment, endoscopic procedures, and surgical interventions. The initial phase of treatment focuses on:
- Fluid resuscitation: Aggressive fluid replacement is crucial, but the optimal rate and type of fluid are still debated 2, 3. Recent studies suggest that moderate fluid replacement may be associated with lower mortality rates compared to aggressive fluid resuscitation 3.
- Early enteral nutrition: Initiation of enteral feeding is recommended to decrease the risk of infected necrosis 4.
- Endoscopic retrograde colangiopancreatography (ERCP): If associated cholangitis is present, ERCP may be necessary 5.
- Intensive care unit (ICU) support: Close monitoring and support are essential for managing the condition 5.
Infection Management
When infection of pancreatic or extrapancreatic necrosis occurs, antimicrobial therapy is indicated 4. The use of broad-spectrum intravenous antibiotics, such as carbapenems, quinolones, and metronidazole, is recommended 4. Routine use of antifungal agents is not recommended unless fungal infection is suspected or confirmed 4.
Interventional Procedures
Drainage and/or debridement of pancreatic necrosis may be necessary in patients with infected necrosis or persistent unwellness 4. A step-up approach, consisting of percutaneous drainage or endoscopic transmural drainage, followed by direct endoscopic necrosectomy, and then surgical debridement, is a reasonable approach 4. Minimally invasive operative approaches, such as videoscopic-assisted retroperitoneal debridement, are preferred to open surgical necrosectomy when possible 4.
Timing of Intervention
The timing of intervention is crucial, and a delayed approach (around 4 weeks) is often recommended to allow for the formation of a "walled-off" necrosis, making it easier to manage 5, 4. Early intervention (within the first 2 weeks) is generally avoided due to increased morbidity and mortality risks 4.
Multidisciplinary Approach
A multidisciplinary team, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition, is essential for optimal management of acute necrotizing pancreatitis 4. Patients with significant pancreatic necrosis may benefit from transfer to a tertiary-care center with expertise in managing this condition 4.