What is the management of necrotizing pancreatitis?

Management of Necrotizing Pancreatitis

The management of necrotizing pancreatitis requires a step-up approach, starting with conservative treatment for sterile necrosis, followed by minimally invasive drainage procedures for infected necrosis, and progressing to more invasive necrosectomy techniques only when necessary. 1, 2

Initial Assessment and Stabilization

• Immediate hemodynamic stabilization with vigorous fluid resuscitation
• Supplemental oxygen as required
• Correction of electrolyte and metabolic abnormalities
• Pain control 3
• Goal-directed fluid therapy (titrated to clinical and biochemical targets) 1
• All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit 3

Diagnostic Evaluation

• CT scan with pancreatic protocol within 3-10 days to assess for necrosis 1
• Severity assessment using APACHE II score, clinical assessment, BMI, and presence of pleural effusion 1
• Monitoring of intra-abdominal pressure in critically ill patients 1

Management of Sterile Necrosis

• Sterile necrosis generally does not require intervention 3
• Conservative management with supportive care is the mainstay of treatment 4
• Monitor for signs of infection (persistent fever, increasing inflammatory markers) 1

Nutritional Support

• Early enteral nutrition (within 24-72 hours) is preferred over parenteral nutrition 1
• Nasojejunal tube feeding using elemental or semi-elemental formula for those unable to tolerate oral intake 3
• Total parenteral nutrition should be used only in those unable to tolerate enteral nutrition 3
• Recommended nutritional intake: 25-35 kcal/kg/day, 1.2-1.5 g/kg/day of protein 1

Antibiotic Management

• Antibiotic prophylaxis is not recommended for sterile necrosis 1, 2
• For infected necrosis, broad-spectrum antibiotics covering gram-negative, gram-positive, and anaerobic organisms should be used 1, 2
• If used for substantial pancreatic necrosis (>30% of gland), antibiotic prophylaxis should continue for no more than 14 days 3
• Suspected infected necrosis should be confirmed by CT-guided fine-needle aspiration for culture 3

Indications for Intervention

Intervention is indicated in:

1. Infected pancreatic necrosis
2. Symptomatic sterile necrosis with:
   • Persistent abdominal pain
   • Gastric/duodenal outlet obstruction
   • Biliary obstruction
   • Persistent unwellness or nutritional failure 2

Step-Up Approach for Infected Necrosis

1. Initial drainage:

   • Percutaneous catheter drainage or
   • Endoscopic transmural drainage 2

2. If inadequate response:

   • Direct endoscopic necrosectomy (DEN) or
   • Minimally invasive surgical necrosectomy 5, 2

3. Last resort:

   • Open surgical necrosectomy 2

Timing of Intervention

• Critical: Avoid pancreatic debridement in the first 2 weeks as it increases morbidity and mortality 2
• Optimal timing for intervention is after 4 weeks when necrosis has become walled-off 2
• Early intervention (<4 weeks) only when there is an organized collection and strong indication 2

Minimally Invasive Techniques

• Percutaneous drainage: Useful in early period (<2 weeks) or for patients too ill for other interventions 2
• Endoscopic transmural drainage: Preferred first-line approach for walled-off necrosis to avoid pancreaticocutaneous fistula 2
• Lumen-apposing metal stents: Superior to plastic stents for endoscopic transmural drainage 2
• Minimally invasive surgical techniques: Video-assisted retroperitoneal debridement (VARD) or minimally invasive retroperitoneal pancreatectomy (MIRP) 5

Management of Complications

• Monitor for development of organ failure, which may require specific supportive measures 1
• Surgical decompression with open abdomen approach may be necessary if abdominal compartment syndrome develops 1
• For disconnected left pancreatic remnant, definitive surgical management with distal pancreatectomy is recommended 2

Referral Considerations

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis 3
• Consider transfer to tertiary care center with appropriate multidisciplinary expertise 2

Audit Standards

• Overall mortality should be lower than 10%, and less than 30% in severe pancreatitis 3, 1
• Correct diagnosis should be made within 48 hours of admission 3
• Severity stratification should be made within 48 hours of diagnosis 3

The management of necrotizing pancreatitis has evolved significantly, with evidence strongly supporting a conservative approach for sterile necrosis and a step-up approach for infected necrosis that prioritizes less invasive techniques before resorting to open surgery 5, 2.