What are the management options for necrotizing pancreatitis?

Management of Necrotizing Pancreatitis

Necrotizing pancreatitis requires a step-up approach starting with conservative management in specialized units, followed by minimally invasive interventions only when infected necrosis is confirmed, with the specific surgical technique depending on local expertise and patient factors. 1

Initial Management and Monitoring

• All patients with severe acute pancreatitis and necrotizing pancreatitis should be managed in a high dependency unit (HDU) or intensive care unit (ICU) with full monitoring and systems support 1, 2
• Severity assessment should be performed within 48 hours of diagnosis using tools such as BISAP score, Modified Glasgow score, or APACHE II score 2
• Implement goal-directed fluid therapy with crystalloids targeting:
  • Urine output >0.5 ml/kg/h
  • Arterial saturation >95%
  • Normalization of heart rate and blood pressure 2
• Avoid overaggressive fluid resuscitation which can lead to respiratory complications and abdominal compartment syndrome 2

Nutritional Support

• Initiate early enteral nutrition (within 24-48 hours) if oral feeding is not tolerated 2
• Either nasogastric or nasojejunal feeding routes are acceptable, with nasogastric being effective in approximately 80% of cases 1, 2
• Enteral nutrition is strongly preferred over parenteral nutrition 2

Antibiotic Management

• Do not routinely administer prophylactic antibiotics in the absence of confirmed infection 2
• If antibiotic prophylaxis is used in cases of extensive pancreatic necrosis, it should be limited to a maximum of 14 days in the absence of positive cultures 1
• Use antibiotics only for specific infections (respiratory, urinary, biliary, or catheter-related) 2

Diagnosis of Infected Necrosis

• All patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration to obtain material for culture 7-14 days after onset 1
• CT scan using a dedicated pancreas protocol should be performed in patients with:
  • Persisting organ failure
  • Signs of sepsis
  • Deterioration in clinical status 6-10 days after admission 1

Intervention for Necrotizing Pancreatitis

When to Intervene

• Intervention is indicated primarily for infected pancreatic necrosis, not sterile necrosis 1
• Delay intervention until walled-off necrosis develops (typically >4 weeks after onset) when possible 1
• In cases of clinical deterioration despite maximal conservative treatment, earlier intervention may be necessary 1

Step-Up Approach for Infected Necrosis

1. Percutaneous catheter drainage (PCD) as initial intervention

   • Allows for drainage of infected fluid collections
   • May be sufficient in up to 56% of patients without requiring further surgical intervention 1
   • Permits delaying surgical intervention to a more favorable time if needed 1

2. Minimally invasive techniques if PCD is insufficient:

   • Endoscopic transmural drainage and necrosectomy
   • Video-assisted retroperitoneal debridement (VARD)
   • Minimally invasive step-up approach 1

3. Open surgical necrosectomy only when minimally invasive approaches fail

   • Complete debridement of all cavities containing necrotic material is essential 1

Selection of Surgical Technique

• The choice of surgical technique for necrosectomy depends on individual features and locally available expertise 1
• Options include:
  • Open necrosectomy with closed drainage
  • Open necrosectomy with open packing
  • Open necrosectomy with closed drainage and continuous lavage 1
  • Single-stage surgical transgastric necrosectomy (for selected cases with walled-off necrosis and disconnected pancreatic duct) 1

Management of Biliary Causes

• For gallstone-induced necrotizing pancreatitis:
  • Urgent ERCP should be performed within 72 hours in patients with cholangitis, jaundice, or dilated common bile duct 1
  • Cholecystectomy should be deferred until fluid collections resolve or stabilize and acute inflammation ceases 1
  • Definitive management of gallstones should occur during the same hospital admission or within two weeks 1

Specialist Care Requirements

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis 1
• A multidisciplinary team approach is essential, including specialists in surgery, endoscopy, intensive care, gastroenterology, and radiology 1
• Every hospital receiving acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 1

Common Pitfalls to Avoid

• Premature surgical intervention before adequate demarcation of necrotic tissue
• Overaggressive fluid resuscitation leading to respiratory complications
• Routine use of prophylactic antibiotics without evidence of infection
• Delayed enteral nutrition, which can worsen outcomes
• Failure to recognize and treat abdominal compartment syndrome
• Delayed referral to specialist centers for severe cases