What are the symptoms and management of necrotizing pancreatitis?

Symptoms and Management of Necrotizing Pancreatitis

Necrotizing pancreatitis is characterized by necrosis of pancreatic parenchyma or extrapancreatic tissues, occurring in 10-20% of acute pancreatitis cases, and requires a step-up approach with delayed intervention, prioritizing percutaneous drainage followed by minimally invasive techniques when necessary. 1, 2

Clinical Presentation and Diagnosis

• Necrotizing pancreatitis presents with persistent symptoms and signs of sepsis in patients with acute pancreatitis, often accompanied by organ failure that persists for more than 48 hours 3
• Diagnosis requires contrast-enhanced CT scan using a dedicated pancreas protocol, optimally performed 72-96 hours after symptom onset to accurately characterize pancreatic necrosis 4, 5
• The extent of pancreatic necrosis directly correlates with mortality risk, with greater necrosis associated with higher likelihood of infected necrosis 6
• Persistent systemic inflammatory response syndrome (SIRS) is common, with a mortality rate of 25.4% compared to 8% with transient SIRS 6

Initial Management

• All patients with severe acute pancreatitis should be managed in a high dependency unit or intensive care unit with full monitoring and systems support 4
• Initial treatment consists of adequate fluid resuscitation and physiological support, as necrotizing pancreatitis is not primarily a surgical disease in the early phase 4
• Avoid prophylactic antibiotics in sterile pancreatic necrosis; antibiotic therapy should be reserved only for cases with signs/symptoms of infection 4
• Early enteral nutrition rather than parenteral nutrition improves outcomes in necrotizing pancreatitis 6
• Avoid over-resuscitation which can lead to abdominal compartment syndrome 1

The 3D Approach: Delay, Drain, Debride

Delay

• Postpone surgical interventions for at least 4 weeks after disease onset, which significantly reduces mortality 1, 5
• Delayed intervention allows better demarcation between necrotic and viable tissue, resulting in less bleeding and more effective necrosectomy 1

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

Debride

• When drainage is insufficient, minimally invasive surgical strategies should be employed 1
• Options include video-assisted retroperitoneal debridement (VARD) and transgastric endoscopic necrosectomy 1, 7
• These minimally invasive strategies result in less new-onset organ failure compared to open surgery 1

Specific Interventions Based on Anatomical Location

• Endoscopic ultrasound (EUS)-guided cystogastrostomy is preferred for central collections abutting the stomach 4
• Percutaneous drainage is appropriate for collections in the early acute period (<2 weeks) or for those with deep extension into paracolic gutters 4
• In selected cases with walled-off necrosis and disconnected pancreatic duct syndrome, a single-stage surgical transgastric necrosectomy may be an option 3, 4

Indications for Intervention

• Infected pancreatic necrosis (primary indication) 4, 8
• Symptomatic sterile necrosis (less common indication) 8
• Complications including gastric outlet, biliary, or intestinal obstruction 4
• Disconnected pancreatic duct syndrome 4
• Ongoing organ failure without signs of infected necrosis (after 4 weeks) 4

Prognosis and Mortality

• Overall mortality in acute necrotizing pancreatitis is approximately 30-40%, significantly higher than the 10-15% mortality rate for all types of acute pancreatitis 6
• Sterile pancreatic necrosis has a mortality rate of 0-11% 6
• Infected pancreatic necrosis carries a substantially higher mortality rate, averaging 40% but potentially exceeding 70% in severe cases 6
• The combination of infected necrosis with organ failure represents the highest risk scenario, with mortality rates of 35.2% 6

Common Pitfalls to Avoid

• Avoid early surgical intervention (within first 2 weeks) as it significantly increases mortality 1, 9
• Don't rely solely on size as the criterion for intervention 4
• Recognize that percutaneous drainage alone has limited success (14-32% cure rate) for definitive treatment of necrotic collections 4
• Do not perform emergency necrosectomy during early surgery for other indications such as abdominal compartment syndrome 1
• For biliary pancreatitis, don't delay definitive treatment of gallstones (usually cholecystectomy) more than two weeks after discharge, but in severe cases wait until signs of lung injury and systemic disturbance have resolved 4