From the Guidelines
Interventions for necrotizing pancreatitis should focus on a step-up approach, starting with minimally invasive techniques like percutaneous catheter drainage or endoscopic transgastric necrosectomy, and reserving open surgical necrosectomy for cases where other approaches fail, as recommended by the most recent guidelines 1. The management of necrotizing pancreatitis has evolved towards a more conservative and minimally invasive approach, with surgery delayed in stable patients.
- Early management includes:
- Aggressive fluid resuscitation
- Pain control with opioid analgesics
- Nutritional support, preferably enteral nutrition via nasojejunal tube
- Prophylactic antibiotics only if infection is suspected
- Infected necrosis, confirmed by fine-needle aspiration or clinical deterioration, requires intervention with a step-up approach, starting with minimally invasive techniques like:
- Percutaneous catheter drainage
- Endoscopic transgastric necrosectomy
- Progressing to video-assisted retroperitoneal debridement if needed
- Open surgical necrosectomy reserved for cases where other approaches fail, as supported by recent studies 1
- Timing is crucial, with intervention ideally delayed until 4 weeks after onset to allow for walled-off necrosis formation, unless the patient shows signs of clinical deterioration, as suggested by guidelines 1
- Drainage of symptomatic pancreatic pseudocysts and management of complications like bleeding or organ failure are also essential components of treatment, aiming to minimize morbidity and mortality associated with necrotizing pancreatitis, as emphasized in recent guidelines 1
From the Research
Interventions for Necrotizing Pancreatitis
The management of necrotizing pancreatitis involves a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition 2. The following interventions are recommended:
- Antimicrobial therapy: Indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected 2, 3, 4.
- Enteral feeding: Should be initiated early to decrease the risk of infected necrosis 2, 5.
- Drainage and/or debridement: Indicated in patients with infected necrosis, and may be required in patients with sterile pancreatic necrosis and persistent unwellness 2, 3, 5.
- Percutaneous drainage: May be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks) 2, 3.
- Endoscopic transmural drainage: May be preferred over percutaneous drainage, as it avoids the risk of forming a pancreatocutaneous fistula 2, 3.
- Direct endoscopic necrosectomy: Should be reserved for patients with limited necrosis who do not adequately respond to endoscopic transmural drainage 2.
- Minimally invasive operative approaches: Preferred to open surgical necrosectomy when possible, given lower morbidity 2, 3.
- Open operative debridement: Maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures 2, 3.
Step-up Approach
A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable 2, 3, 5. This approach allows for a tailored treatment strategy based on the individual patient's needs and response to treatment.
Antibiotic Prophylaxis
Antibiotic prophylaxis is not recommended for preventing septic complications in acute pancreatitis 3, 6, 4. However, therapeutic antibiotics are required for treatment of documented infected pancreatic necrosis 2, 3.