What is the best management strategy for infected pancreatic necrosis after intravenous (IV) antibiotics?

Management of Infected Pancreatic Necrosis After IV Antibiotics

The best management strategy for infected pancreatic necrosis after IV antibiotics is a step-up approach starting with percutaneous or endoscopic drainage, followed by minimally invasive necrosectomy techniques only if necessary. 1

Diagnostic Confirmation of Infected Necrosis

• Procalcitonin (PCT) is the most sensitive laboratory marker for detecting pancreatic infection and low values are strong negative predictors of infected necrosis 1, 2
• CT-guided fine-needle aspiration (FNA) for Gram stain and culture can confirm infection and guide antibiotic therapy, though it has a high false-negative rate and is no longer in routine use at many centers 1, 3
• The presence of gas in the retroperitoneal area on CT imaging is considered indicative of infected pancreatitis 1

Step-Up Approach for Management

First Line: Drainage Procedures

• Percutaneous drainage should be the first intervention in the step-up approach for infected pancreatic necrosis 1, 3
• Endoscopic transmural drainage is an appropriate alternative first-line approach, particularly for walled-off pancreatic necrosis (WON) 3, 4
• Endoscopic drainage may be preferred as it avoids the risk of forming a pancreatocutaneous fistula 3
• Percutaneous or endoscopic drainage alone is successful in resolving infected necrosis in 25-60% of patients without requiring further intervention 1, 4

Second Line: Minimally Invasive Necrosectomy

If drainage procedures fail to control infection, proceed to minimally invasive necrosectomy:

• Video-assisted retroperitoneal debridement (VARD) 1, 5
• Endoscopic necrosectomy through transgastric approach 1, 3
• Minimally invasive retroperitoneal pancreatic necrosectomy 5

These approaches result in less new-onset organ failure compared to open surgery but may require multiple interventions 1, 5

Third Line: Open Surgical Necrosectomy

• Reserved for cases not amenable to less invasive procedures 3, 6
• Should be delayed for at least 4 weeks after onset of pancreatitis when possible to allow for better demarcation of necrotic tissue 1
• Emergency surgery may be needed earlier for abdominal compartment syndrome, acute ongoing bleeding when endovascular approach fails, or bowel ischemia 1

Antibiotic Management

• Continue antibiotics that penetrate pancreatic necrosis effectively (carbapenems, quinolones with metronidazole) 1, 2
• Limit antibiotic therapy to 7 days if adequate source control is achieved 1, 2
• Patients with ongoing signs of infection beyond 7 days warrant further diagnostic investigation 1, 2
• Routine antifungal prophylaxis is not recommended despite Candida being common in infected pancreatic necrosis 1

Nutritional Support

• Enteral feeding should be initiated early to decrease risk of infected necrosis 1, 3
• When oral nutrition is not feasible, enteral nutrition by nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible 3
• Total parenteral nutrition should be considered only when enteral feeds are not feasible or tolerated 3

Timing Considerations

• Postponing surgical interventions for more than 4 weeks after disease onset results in lower mortality 1
• Debridement should be avoided in the early, acute period (first 2 weeks) as it has been associated with increased morbidity and mortality 3, 5
• With delayed surgery, better demarcation of necrosis from vital tissue occurs, resulting in less bleeding and more effective necrosectomy 1

Special Considerations

• For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be considered 3
• In selected cases with walled-off necrosis and disconnected pancreatic duct, a single-stage surgical transgastric necrosectomy is an option 1
• Minimally invasive strategies require more interventions but result in less new-onset organ failure compared to open surgery 1, 5