Management and Treatment of Necrotizing Pancreatitis
The management of necrotizing pancreatitis requires a step-up approach summarized as "Delay, Drain, and Debride," with initial conservative management focused on resuscitation and physiological support, followed by minimally invasive drainage procedures, and surgical debridement only when necessary for infected necrosis. 1
Initial Management
- All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive therapy unit with full monitoring and systems support 1
- Initial treatment consists of adequate fluid resuscitation and physiological restoring procedures, as necrotizing pancreatitis is not primarily a surgical disease in the early phase 1
- Early enteral nutrition should be initiated to decrease the risk of infected necrosis 2
- Avoid prophylactic antibiotics in sterile pancreatic necrosis; antibiotic therapy should be reserved only for cases with signs/symptoms of infection 1, 2
Diagnosis of Infected Necrosis
- All patients with persistent symptoms and greater than 30% pancreatic necrosis, or those with smaller areas of necrosis and clinical suspicion of sepsis, should undergo image-guided fine needle aspiration (FNA) to obtain material for culture 7-14 days after the onset of pancreatitis 1
- CT scan using a dedicated pancreas protocol is indicated for patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6-10 days after admission 1
- Infected necrosis should be suspected with persistent fever, leukocytosis, organ failure, or a protracted severe clinical course 3
Intervention for Necrotizing Pancreatitis
Timing of Intervention
- Surgical debridement should be avoided in the early, acute period (first 2 weeks) as it has been associated with increased morbidity and mortality 2
- Intervention should be optimally delayed for 4 weeks to allow necrotic tissue to become demarcated 2, 4
Step-Up Approach
Initial Drainage:
- Percutaneous catheter drainage or endoscopic (transgastric/transduodenal) drainage is the preferred first-line approach 5, 2
- Endoscopic ultrasound (EUS)-guided cystogastrostomy is preferred for central collections abutting the stomach 6
- Percutaneous drainage is appropriate for collections in the early acute period (<2 weeks) or for those with deep extension into paracolic gutters 6, 2
Necrosectomy (if needed):
Open Necrosectomy:
Indications for Intervention
- Infected pancreatic necrosis (confirmed by culture) 2
- Persistent unwellness with abdominal pain, nausea, vomiting, and nutritional failure 2
- Complications including gastric outlet, biliary, or intestinal obstruction 6
- Disconnected pancreatic duct syndrome 6
- Ongoing organ failure without signs of infected necrosis (after 4 weeks) 6
Management of Specific Complications
- For biliary pancreatitis, definitive treatment of gallstones (usually cholecystectomy) should not be delayed more than two weeks after discharge 1
- Cholecystectomy should be delayed in patients with severe acute pancreatitis until signs of lung injury and systemic disturbance have resolved 1
- For disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in suitable candidates 2
Common Pitfalls to Avoid
- Avoid early surgical intervention (<4 weeks after disease onset) as it results in higher mortality 6, 4
- Don't rely solely on size as the criterion for intervention 6
- Avoid prophylactic antibiotics to prevent infection of sterile necrosis 2
- Recognize that percutaneous drainage alone has limited success (14-32% cure rate) for definitive treatment of necrotic collections 6
- Don't delay transfer to a tertiary care center for patients with significant pancreatic necrosis when local expertise is limited 2