From the Guidelines
The treatment of necrotizing pancreatitis requires a multidisciplinary approach focusing initially on supportive care, with a step-up approach for intervention, starting with less invasive procedures like percutaneous drainage or endoscopic transgastric drainage, as recommended by the most recent guidelines 1.
Key Components of Treatment
- Early management includes aggressive fluid resuscitation with isotonic crystalloids, pain control with opioid analgesics, and nutritional support.
- Enteral nutrition via nasojejunal tube is preferred over parenteral nutrition when possible, ideally started within 48-72 hours.
- Antibiotics are not routinely recommended prophylactically but should be initiated when infection is suspected or confirmed, with imipenem, meropenem, or a combination of quinolones and metronidazole being common choices.
Intervention Approach
- Infected necrosis typically requires intervention, but the current approach favors delayed intervention (preferably after 4 weeks) to allow for walling-off of the necrotic collection.
- A step-up approach is recommended, starting with less invasive procedures like percutaneous drainage or endoscopic transgastric drainage before considering minimally invasive surgical necrosectomy if needed.
- Open surgical necrosectomy is reserved for cases not responding to less invasive approaches, as supported by recent guidelines 1 and studies 1.
Rationale
- This staged management strategy has significantly reduced mortality compared to immediate surgical intervention, as it allows time for the inflammatory response to subside and the necrotic tissue to demarcate, making subsequent interventions safer and more effective.
- The approach is also supported by the concept of the "3Ds": Delay, Drain, and Debride, as outlined in recent guidelines 1, which emphasizes the importance of delaying intervention, draining infected collections, and debriding necrotic tissue in a step-wise manner.
From the Research
Treatment Approach for Necrotizing Pancreatitis
The treatment of necrotizing pancreatitis involves a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition 2. The management strategy is individualized for each patient and may involve a combination of medical and surgical interventions.
Medical Management
- Goal-directed fluid resuscitation to avoid over-resuscitation and abdominal compartment syndrome 3
- Early enteral nutrition support to decrease the risk of infected necrosis 3, 4, 2
- Antibiotic prophylaxis is not recommended, but therapeutic antibiotics are required for treatment of documented infected pancreatic necrosis 3, 2
- Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected 2
Surgical Management
- Surgical approach is considered when infection of pancreatic or extrapancreatic necrosis occurs 4
- A "step-up" approach is recommended, starting with percutaneous drainage or endoscopic transmural drainage, followed by minimally invasive or endoscopic necrosectomy if necessary 3, 5, 4, 2, 6
- Open necrosectomy is associated with substantial morbidity, but may be necessary in some cases 3, 5, 2
- Minimally invasive operative approaches, such as videoscopic-assisted retroperitoneal debridement, are preferred to open surgical necrosectomy when possible 2
Interventional Procedures
- Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON) 2
- Self-expanding metal stents are superior to plastic stents for endoscopic transmural drainage of necrosis 2
- Direct endoscopic necrosectomy should be reserved for patients with limited necrosis who do not adequately respond to endoscopic transmural drainage 2