What is the treatment for necrotizing pancreatitis?

Treatment of Necrotizing Pancreatitis

The optimal treatment of 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, managed by a multidisciplinary team at a specialized center. 1

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 2, 3
• Initial treatment consists of adequate fluid resuscitation and physiological support, as necrotizing pancreatitis is not primarily a surgical disease in the early phase 2, 3
• Avoid prophylactic antibiotics in sterile pancreatic necrosis; antibiotic therapy should be reserved only for cases with signs/symptoms of infection 2, 3
• Early enteral nutrition rather than parenteral nutrition improves outcomes and should be initiated to decrease the risk of infected necrosis 3, 4
• Pain management is a clinical priority, with dilaudid preferred over morphine or fentanyl in non-intubated patients 5

The 3D Approach: Delay, Drain, Debride

Delay

• Postpone surgical interventions for at least 4 weeks after disease onset, which significantly reduces mortality 1, 6
• Early surgical intervention (within first 2 weeks) significantly increases mortality and should be avoided 1, 4
• 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, 7
• Percutaneous drainage can completely resolve infection in 25-60% of patients without requiring further surgical intervention 1, 8
• Endoscopic ultrasound (EUS)-guided cystogastrostomy is preferred for central collections abutting the stomach 2
• Percutaneous drainage is appropriate for collections in the early acute period (<2 weeks) or for those with deep extension into paracolic gutters 2, 4

Debride

• When drainage is insufficient, minimally invasive surgical strategies should be employed 1, 9
• Minimally invasive approaches include video-assisted retroperitoneal debridement (VARD) and transgastric endoscopic necrosectomy 1, 9
• These minimally invasive strategies result in less new-onset organ failure compared to open surgery (12% vs. 40%) 8
• In selected cases with walled-off necrosis and disconnected pancreatic duct syndrome, a single-stage surgical transgastric necrosectomy may be an option 1, 2

Indications for Intervention

• Infected pancreatic necrosis (primary indication) 3, 4
• Complications including gastric outlet, biliary, or intestinal obstruction 2, 3
• Disconnected pancreatic duct syndrome 2, 3
• Ongoing organ failure without signs of infected necrosis (after 4 weeks) 2, 3

Management of Specific Complications

• For biliary pancreatitis, definitive treatment of gallstones (usually cholecystectomy) should not be delayed more than two weeks after discharge 2
• Cholecystectomy should be delayed in patients with severe acute pancreatitis until signs of lung injury and systemic disturbance have resolved 2
• For abdominal compartment syndrome unresponsive to conservative management, surgical decompression may be necessary 1, 3

Common Pitfalls to Avoid

• Avoid early surgical intervention (within first 2 weeks) as it significantly increases mortality 1, 4
• Avoid over-resuscitation which can lead to abdominal compartment syndrome 1, 3
• Do not perform emergency necrosectomy during early surgery for other indications such as abdominal compartment syndrome or bowel necrosis 1
• Don't rely solely on size as the criterion for intervention 2
• Recognize that percutaneous drainage alone has limited success (14-32% cure rate) for definitive treatment of necrotic collections 2, 4

Long-term Outcomes and Sequelae

• Following step-up approach treatment, approximately 27% of patients develop exocrine pancreatic insufficiency 7
• About 45% of patients develop or experience worsening of diabetes 7
• Pancreatic fistula occurs in approximately 24% of cases 7
• The step-up approach results in lower rates of incisional hernias (7% vs. 24%) and new-onset diabetes (16% vs. 38%) compared to open necrosectomy 8