What is the safer approach in managing acute pancreatitis?

Safer Approach in Managing Acute Pancreatitis

The safest approach to managing acute pancreatitis is a step-up approach that prioritizes delayed intervention, starting with percutaneous drainage as first-line treatment for infected necrosis, followed by minimally invasive techniques only when necessary, and should be managed by a multidisciplinary team at a specialized center. 1

Initial Management

• Patients with severe acute pancreatitis should be managed in an HDU or ICU setting with full monitoring and systems support 2
• Early aggressive fluid resuscitation is crucial within the first 12-24 hours of presentation 3
• Enteral nutrition is preferred over parenteral nutrition to prevent gut failure and infectious complications 2
• Enteral feeding should be initiated early via nasogastric or nasojejunal tube 2

The 3D Approach: Delay, Drain, Debride

Delay

• Postpone surgical interventions for at least 4 weeks after disease onset, which significantly reduces mortality 4, 1
• Delayed intervention allows better demarcation between necrotic and viable tissue, resulting in less bleeding and more effective necrosectomy 4
• A majority of patients with sterile necrotizing pancreatitis can be managed without interventions 4

Drain

• In infected pancreatic necrosis, percutaneous drainage is recommended as the first line of treatment (step-up approach) 4, 1
• Percutaneous drainage can completely resolve infection in 25-60% of patients without requiring further surgical intervention 1
• When a patient deteriorates, a step-up approach starting with percutaneous or endoscopic drainage is indicated 4

Debride

• When drainage is insufficient, minimally invasive surgical strategies should be employed 4, 1
• Minimally invasive approaches include video-assisted retroperitoneal debridement (VARD) and transgastric endoscopic necrosectomy 1
• These minimally invasive strategies result in less new-onset organ failure compared to open surgery 4

Indications for Intervention

• Abdominal compartment syndrome unresponsive to conservative management 4
• Acute ongoing bleeding when endovascular approach is unsuccessful 4
• Bowel ischemia or acute necrotizing cholecystitis during acute pancreatitis 4
• Bowel fistula extending into a peripancreatic collection 4
• Infected necrosis with clinical deterioration (preferably after 4 weeks) 2

Management of Biliary Pancreatitis

• Urgent ERCP should be performed in patients with acute pancreatitis of suspected or proven gallstone etiology who have cholangitis, jaundice, or a dilated common bile duct 2
• Laparoscopic cholecystectomy during index admission is recommended in mild acute gallstone pancreatitis 4
• In acute gallstone pancreatitis with peripancreatic fluid collections, cholecystectomy should be deferred until fluid collections resolve or stabilize 4

Antibiotic Management

• Routine use of prophylactic antibiotics in patients with severe AP and/or sterile necrosis is not recommended 3
• Antibiotics should be administered when specific infections occur 2
• In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention 3, 5

Common Pitfalls to Avoid

• Avoid early surgical intervention (within first 2 weeks) as it significantly increases mortality 1
• Avoid over-resuscitation which can lead to abdominal compartment syndrome 1
• Do not perform emergency necrosectomy during early surgery for other indications 1
• Avoid open abdomen after necrosectomy unless severe intra-abdominal hypertension mandates it 4

Special Considerations

• In selected cases with walled-off necrosis and in patients with disconnected pancreatic duct, a single-stage surgical transgastric necrosectomy may be an option 4
• Management of patients with >30% pancreatic necrosis should prompt discussion with or referral to a specialist unit 2
• A small subset of patients with infected necrosis may be managed successfully with conservative management and prolonged courses of antibiotics without surgical intervention 5