From the Guidelines
Necrotizing pancreatitis should be managed with a conservative approach, delaying intervention until at least 4 weeks after onset, and using a step-up approach starting with percutaneous drainage, as recommended by the most recent guidelines 1.
Diagnosis and Initial Management
Necrotizing pancreatitis is a severe form of acute pancreatitis characterized by tissue death in and around the pancreas. Initial management focuses on aggressive fluid resuscitation with isotonic crystalloids, pain control with opioid analgesics, and nutritional support. Early enteral nutrition through a nasojejunal tube is preferred over parenteral nutrition to maintain gut barrier function and reduce infection risk.
Antibiotic Use and Infection Management
Antibiotics are not routinely recommended unless there is confirmed infection. For infected necrosis, broad-spectrum antibiotics like meropenem or a combination of metronidazole and a quinolone should be initiated, as supported by previous guidelines 1. However, the most recent guidelines emphasize that antibiotics should be reserved only for cases with signs or symptoms of infection 1.
Intervention and Surgical Management
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, starting with less invasive procedures like percutaneous drainage before considering minimally invasive surgical necrosectomy if necessary, as recommended by the 2019 WSES guidelines 1. This approach is further supported by the most recent guidelines, which summarize the contemporary approach to patients with necrotizing pancreatitis as the "3Ds": Delay, Drain, and Debride 1.
Key Considerations
- Delay intervention until at least 4 weeks after onset to allow for walling-off of the necrosis
- Use a step-up approach starting with percutaneous drainage
- Reserve antibiotics for cases with confirmed infection
- Monitor closely for complications, including organ failure, compartment syndrome, and secondary infections
- Consider minimally invasive surgical necrosectomy if necessary, as part of the step-up approach 1.
From the Research
Diagnosis of Necrotizing Pancreatitis
- The diagnosis of necrotizing pancreatitis (NP) involves imaging techniques such as computed tomography (CT) to verify the presence of necrotic tissue and fluid collections 2, 3.
- Laboratory tests, including blood cultures and microbiological analysis, are used to identify the causative organisms and guide antibiotic therapy 2, 4.
- Clinical evaluation, including assessment of symptoms such as abdominal pain, nausea, and vomiting, is also crucial in diagnosing NP 2, 3.
Treatment of Necrotizing Pancreatitis
- The management of NP has evolved from open surgical necrectomy to minimally invasive techniques, such as percutaneous catheter drainage (PCD) and endoscopic ultrasound (EUS)-guided drainage 2, 5, 3.
- A step-up approach, consisting of PCD or EUS-guided drainage, followed by minimally invasive necrosectomy if necessary, is recommended for the treatment of infected necrotizing pancreatitis (INP) 5, 3.
- Conservative management, including fluid resuscitation, nutritional support, and broad-spectrum antibiotics, is used for patients with non-infected NP or those who are not candidates for invasive interventions 3, 4.
- A multidisciplinary team approach, involving advanced endoscopists, interventional radiologists, pancreaticobiliary surgeons, and other specialists, is essential for the optimal management of severe NP 3.
Indications for Intervention
- Infected necrotic peripancreatic fluid collection (PFC) and/or persistent severe symptoms due to mass effect are indications for further invasive interventions 3, 4.
- The presence of "walled-off necrosis" is a key factor in determining the timing of intervention, with delayed intervention recommended to allow necrotic tissue to become demarcated 5, 4.
- Dual modalities, such as percutaneous and endoscopic drainage, may be used to reduce complications and improve patient outcomes 3.