What is the treating philosophy for acute necrotizing pancreatitis?

Treatment Philosophy for Acute Necrotizing Pancreatitis

The optimal treatment of acute necrotizing pancreatitis requires a step-up approach with delayed intervention, prioritizing percutaneous drainage as first-line treatment, followed by minimally invasive techniques only when necessary, and should be managed by a multidisciplinary team at a specialized center. 1

Initial Management Approach

• Patients with necrotizing pancreatitis should be managed by a multidisciplinary team including specialists in surgery, gastroenterology, interventional radiology, and critical care 2
• Approximately 62% of patients with necrotizing pancreatitis can be treated conservatively without any intervention, with a mortality rate of only 7% 3
• Early enteral feeding should be initiated to decrease the risk of infected necrosis 2
• Antibiotic prophylaxis is not recommended for sterile necrosis; antibiotics should be reserved for culture-proven infection or when infection is strongly suspected 2

The 3D Approach: Delay, Drain, Debride

Delay

• Postpone surgical interventions for at least 4 weeks after disease onset, which results in significantly reduced mortality 1
• Early surgery (within first 2 weeks) is associated with increased morbidity and mortality and should be avoided 2, 4
• Delayed intervention allows better demarcation between necrotic and viable tissue, resulting in less bleeding and more effective necrosectomy 1
• Mortality rates decrease significantly with longer time between admission and intervention: 56% (0-14 days), 26% (14-29 days), and 15% (>29 days) 3

Drain

• In infected pancreatic necrosis, percutaneous drainage is recommended as the first line of treatment (step-up approach) 1
• Percutaneous drainage can completely resolve infection in 25-60% of patients without requiring further surgical intervention 1
• Percutaneous drainage allows delaying any subsequent surgical intervention to a more favorable time 1
• Endoscopic transmural drainage is an appropriate alternative first-line approach for walled-off pancreatic necrosis (WON) 2

Debride

• When drainage is insufficient, minimally invasive surgical strategies should be employed 1
• Minimally invasive approaches include:
  • Video-assisted retroperitoneal debridement (VARD) 1
  • Transgastric endoscopic necrosectomy 1
  • Direct endoscopic necrosectomy (DEN) 2
• These minimally invasive strategies result in less new-onset organ failure compared to open surgery, though they may require more interventions 1
• Open surgical necrosectomy should be reserved for cases refractory to minimally invasive approaches 5, 6

Special Considerations

• Patients with pancreatic parenchymal necrosis have higher risk of organ failure (50% vs 24%) and mortality (20% vs 9%) compared to those with only peripancreatic necrosis 3
• In selected cases with walled-off necrosis and in patients with disconnected pancreatic duct, a single-stage surgical transgastric necrosectomy may be an option 1
• Management of patients with >30% pancreatic necrosis should prompt discussion with or referral to a specialist unit 1
• For patients with abdominal compartment syndrome unresponsive to conservative management, surgical decompression may be necessary 1

Common Pitfalls to Avoid

• Avoid early surgical intervention (within first 2 weeks) as it significantly increases mortality 1, 2
• Avoid over-resuscitation which can lead to abdominal compartment syndrome 1
• Do not use prophylactic antibiotics for sterile necrosis 2
• Avoid total parenteral nutrition when enteral feeding is possible 2
• Do not perform emergency necrosectomy during early surgery for other indications such as abdominal compartment syndrome or bowel necrosis 1

The evidence strongly supports that the modern treatment philosophy for acute necrotizing pancreatitis has shifted from early aggressive surgical debridement to a more conservative, step-up approach with delayed intervention, which has significantly improved patient outcomes 5, 6, 3.