What is the correct approach to treating pancreatic necrosis and infection?

Management of Pancreatic Necrosis and Infection

Early enteral feeding via a nasal-jejunal tube passed beyond the ligament of Treitz is associated with decreased development of infected pancreatic necrosis and should be initiated as soon as possible in patients with necrotizing pancreatitis.

Nutritional Management in Pancreatic Necrosis

• Enteral nutrition should be initiated early via nasojejunal tube (preferred route) or nasogastric tube in patients with severe acute pancreatitis and necrotizing pancreatitis to prevent gut failure and infectious complications 1
• Oral food intake can be initiated within 24 hours after minimally invasive necrosectomy if the patient's clinical state (hemodynamic stability, septic parameters, gastric emptying) allows it 1
• For patients unable to tolerate oral feeding, enteral nutrition via nasojejunal tube is the preferred route following minimally invasive necrosectomy 1
• Parenteral nutrition should be reserved only for patients who cannot tolerate enteral nutrition or when enteral nutrition is contraindicated 1

Management of Intra-abdominal Pressure (IAP)

• In patients with severe acute pancreatitis and IAP < 15 mmHg, early enteral nutrition should be initiated via nasojejunal (preferred) or nasogastric tube with continuous monitoring of IAP and clinical condition 1
• For patients with IAP > 15 mmHg, enteral nutrition should be initiated via nasojejunal route starting at 20 mL/h, with rate increases based on tolerance 1
• When IAP exceeds 20 mmHg or abdominal compartment syndrome develops, enteral nutrition should be temporarily discontinued and parenteral nutrition initiated 1

Timing of Intervention for Pancreatic Necrosis

• Interventions for infected necrosis should be delayed until at least 4 weeks after disease onset when possible, as this results in lower mortality 2, 3
• Early operative debridement (within first 2 weeks) of pancreatic necrosis is associated with increased morbidity and mortality and should be avoided 3
• A step-up approach should be implemented for infected necrosis, starting with percutaneous or endoscopic drainage and progressing to minimally invasive necrosectomy if no improvement occurs 2, 3

Indications for Early Intervention

• Abdominal compartment syndrome unresponsive to conservative management 2, 4
• Acute ongoing bleeding when endovascular approach is unsuccessful 2, 4
• Bowel ischemia or acute necrotizing cholecystitis 2, 4
• Infected necrosis with clinical deterioration 2, 4

Antibiotic Management

• Prophylactic antibiotics are not routinely recommended for prevention of pancreatic necrosis infection 2, 3
• Antibiotics should be administered only when specific infections occur or when infection is strongly suspected (gas in collection, bacteremia, sepsis, clinical deterioration) 2, 3
• When infected necrosis is suspected, broad-spectrum antibiotics with ability to penetrate pancreatic necrosis should be used (e.g., carbapenems, quinolones, and metronidazole) 3

Diagnostic Approach

• Dynamic CT scanning should be obtained within 3-10 days of admission using non-ionic contrast to assess the extent of necrosis 4
• When infection is suspected in a necrotic collection, CT-guided fine-needle aspiration may be performed for culture and Gram stain to document infection, though this is unnecessary in the majority of cases 5, 3

Referral Considerations

• Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis who may require intensive care, interventional radiological, endoscopic, or surgical procedures 2, 4
• A multidisciplinary approach involving gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine is essential for optimal management 3

Common Pitfalls and Caveats

• Simple drainage procedures without debridement of necrotic material may predispose to infection when pancreatic necrosis is unrecognized 5
• Percutaneous drainage alone has limited success (14-32% cure rate) for definitive treatment of necrotic collections 5
• Evaluate main pancreatic duct status, as complete occlusion central to the pseudocyst may lead to failure of percutaneous drainage 5