From the Guidelines
The management of acute necrotizing pancreatitis should prioritize a step-up approach, starting with percutaneous drainage or endoscopic transgastric drainage, followed by minimally invasive necrosectomy if necessary, as recommended by the 2019 WSES guidelines 1. The initial management includes aggressive fluid resuscitation with isotonic crystalloids to maintain adequate organ perfusion, pain control with opioid analgesics, and nutritional support.
- Early enteral nutrition via nasojejunal or nasogastric tube should be started within 48-72 hours to maintain gut barrier function and reduce infectious complications.
- Prophylactic antibiotics are not recommended unless there is confirmed infection, as stated in the 2023 WSES guidelines 1. For infected necrosis, broad-spectrum antibiotics like imipenem/cilastatin, meropenem, or a combination of ciprofloxacin and metronidazole should be initiated.
- Intervention for necrotic collections should be delayed until at least 4 weeks after onset to allow for walling-off of the necrosis.
- The step-up approach is preferred, as it results in less new-onset organ failure but requires more interventions, as noted in the 2019 WSES guidelines 1. Organ failure should be managed aggressively with appropriate support measures, including mechanical ventilation, vasopressors, and renal replacement therapy as needed.
- A multidisciplinary group of experts should individualize surgical treatment, taking local expertise into account, as recommended by the 2019 WSES guidelines 1. This approach minimizes complications and mortality by addressing both the local pancreatic inflammation and systemic inflammatory response, ultimately improving morbidity, mortality, and quality of life outcomes.
From the Research
Management of Acute Necrotizing Pancreatitis
The management of acute necrotizing pancreatitis involves a multidisciplinary approach, including:
- Fluid resuscitation: Aggressive intravenous fluid resuscitation is recommended in all patients with acute pancreatitis, with the goal of preventing organ failure and promoting recovery 2.
- Early enteral nutrition: Early enteral nutrition is recommended to support the patient's nutritional needs and prevent complications 3, 4.
- Endoscopic retrograde cholangiopancreatography (ERCP): ERCP may be indicated in patients with biliary pancreatitis to remove common bile duct stones 3, 5.
- Antibiotic prophylaxis: Antibiotic prophylaxis is not recommended for all patients with acute necrotizing pancreatitis, but may be indicated in patients with infected pancreatic necrosis 4, 6.
- Surgical intervention: Surgical intervention may be necessary in patients with infected pancreatic necrosis or deterioration of the patient's condition despite maximal conservative therapy 3, 4, 5, 6.
Surgical Approaches
Surgical approaches for acute necrotizing pancreatitis include:
- Open necrosectomy: Open necrosectomy is a traditional approach, but is associated with substantial morbidity 4, 6.
- Minimally invasive techniques: Minimally invasive techniques, such as video-assisted retroperitoneal debridement (VARD), minimally invasive retroperitoneal pancreatectomy (MIRP), or transluminal direct endoscopic necrosectomy (DEN), are gaining popularity and may be associated with reduced morbidity 3, 4, 6.
- Step-up approach: A step-up approach, starting with catheter drainage if needed, followed by minimally invasive surgical or endoscopic necrosectomy, is a recommended approach for managing infected pancreatic necrosis 3, 4, 6.
Multidisciplinary Approach
A multidisciplinary approach, including a team of interventional radiologists, therapeutic endoscopists, and surgeons, is essential for the management of acute necrotizing pancreatitis 3, 4.