From the Guidelines
Necrotizing pancreatitis treatment involves a step-up approach, starting with percutaneous drainage as the first line of treatment.
Treatment Overview
- The step-up approach allows for delaying surgical treatment to a more favorable time or even results in complete resolution of infection in 25–60% of patients 1.
- Minimally invasive surgical strategies, such as transgastric endoscopic necrosectomy or video-assisted retroperitoneal debridement (VARD), result in less postoperative new-onset organ failure but require more interventions 1.
- The management options include open surgery, mini-invasive surgery, endoscopic surgery, and a combination of these, with no differences in mortality found between them 1.
Key Considerations
- A multidisciplinary group of experts should individualize surgical treatment taking local expertise into account 1.
- Percutaneous drainage allows for delaying the later possible surgical intervention to a more favorable time 1.
- Clinical deterioration with signs or strong suspicion of infected necrotizing pancreatitis is an indication to perform intervention (percutaneous/endoscopic drainage) 1.
Surgical Approach
- In selected cases with walled-off necrosis and in patients with disconnected pancreatic duct, a single-stage surgical transgastric necrosectomy is an option 1.
- Thorough debridement of necrotic tissue is essential during any surgical intervention, with no clear evidence to support one surgical technique over another 1.
From the Research
Treatment Options for Necrotizing Pancreatitis
The treatment for necrotizing pancreatitis can be either conservative or invasive, depending on the severity of the condition and the presence of infection.
- Conservative treatment is often used for patients with sterile necrosis, and emphasizes supportive measures and prevention of infection and other complications 2.
- Invasive treatment, such as catheter drainage, minimally invasive surgical or endoscopic necrosectomy, is typically reserved for patients with infected necrosis or those who have not responded to conservative treatment 2, 3.
Intervention Strategies
The optimal timing for intervention in acute necrotizing pancreatitis is still a topic of debate.
- Early intervention, within 4 weeks of symptom onset, may involve drainage via percutaneous, endoscopic, or combined methods, but is associated with higher mortality 4.
- Delayed intervention, after 4 weeks of symptom onset, can be conducted either surgically or via minimally invasive means, and is associated with fewer complications and better outcomes 4.
Minimally Invasive Techniques
Minimally invasive techniques, such as percutaneous catheter drainage (PCD), have emerged as a crucial component of the step-up approach in managing infected necrotizing pancreatitis.
- PCD has been shown to be a safe and effective treatment for infected necrotizing pancreatitis, with lower mortality and morbidity rates compared to open necrectomy 5.
- Endoscopic drainage and direct endoscopic necrosectomy are also viable options for the management of necrotizing pancreatitis, and can be facilitated by the use of plastic or metallic stents 6.
Multidisciplinary Approach
A multidisciplinary team with appropriate expertise is essential for the care of patients with necrotizing pancreatitis.
- The treatment approach should be individualized based on the location of the retroperitoneal collection, previous gastric surgery, patient preference, and medical expertise 6.
- A step-up approach, starting with conservative treatment and progressing to invasive treatment as needed, can help to improve outcomes and reduce complications in patients with necrotizing pancreatitis 2, 3.