How is pancreatic ischemia or necrosis managed in a patient with pancreatitis?

Management of Pancreatic Ischemia or Necrosis in Pancreatitis

Pancreatic necrosis should be managed with initial intensive supportive care, delayed intervention (≥4 weeks when possible), and a step-up approach prioritizing percutaneous or endoscopic drainage before minimally invasive debridement, with all patients requiring management by a multidisciplinary team in a specialized center. 1, 2, 3

Initial Management and Supportive Care

All patients with necrotizing pancreatitis require admission to a high dependency unit or intensive care unit with full monitoring and systems support. 1, 4 The critical early interventions include:

• Adequate fluid resuscitation while avoiding over-resuscitation that can lead to abdominal compartment syndrome 1, 4
• Early enteral nutrition (oral, nasogastric, or nasojejunal) rather than parenteral nutrition to decrease the risk of infected necrosis 5, 1, 3
• Pain management with dilaudid preferred over morphine or fentanyl in non-intubated patients 1
• No prophylactic antibiotics for sterile pancreatic necrosis—antibiotics should be reserved only for documented or strongly suspected infection 1, 4, 3

The 3D Approach: Delay, Drain, Debride

Delay: Postpone Intervention

Surgical interventions must be delayed for at least 4 weeks after disease onset, as early intervention (within first 2 weeks) significantly increases mortality. 1, 2, 4 This delay allows:

• Better demarcation between necrotic and viable tissue 1, 2
• Reduced bleeding during necrosectomy 1
• Formation of a walled-off collection that is more amenable to minimally invasive techniques 3

Critical pitfall to avoid: Emergency necrosectomy during early surgery for other indications (such as abdominal compartment syndrome or bowel necrosis) should never be performed. 1, 2

Drain: First-Line Intervention

When intervention is required, percutaneous or endoscopic drainage is the recommended first-line treatment (step-up approach). 1, 2, 3

Percutaneous drainage:

• Can completely resolve infection in 25-60% of patients without requiring further surgical intervention 1, 2, 4
• Preferred for collections in the early acute period (<2 weeks), collections in the tail of the pancreas, or those with deep extension into paracolic gutters and pelvis 2, 4, 3
• Allows delaying subsequent surgical intervention to a more favorable time 2

Endoscopic drainage:

• EUS-guided cystogastrostomy is preferred for central collections abutting the stomach 1, 2, 4
• Avoids the risk of forming a pancreatocutaneous fistula 3
• Lumen-apposing metal stents appear superior to plastic stents for transmural drainage 3

Debride: When Drainage is Insufficient

When drainage alone is insufficient, minimally invasive surgical strategies should be employed before considering open necrosectomy. 1, 2, 4

Minimally invasive approaches include:

• Video-assisted retroperitoneal debridement (VARD) 1, 2, 3
• Transgastric endoscopic necrosectomy 1, 2, 3
• Laparoscopic transgastric debridement 3

These minimally invasive strategies result in less new-onset organ failure compared to open surgery, though they may require multiple interventions. 2, 3

Direct endoscopic necrosectomy should be reserved for patients who do not adequately respond to drainage alone or those with large amounts of infected necrosis, and should only be performed at referral centers with necessary expertise. 3

Indications for Intervention

Intervention is indicated for:

• Infected pancreatic necrosis (primary indication) 1, 4, 3
• Complications including gastric outlet, biliary, or intestinal obstruction 1, 4
• Disconnected pancreatic duct syndrome 1, 4
• Ongoing organ failure without signs of infected necrosis after 4 weeks 1, 4
• Persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure in sterile necrosis 3

Antibiotic Management

Antibiotics should only be used for documented or strongly suspected infected necrosis, not prophylactically. 1, 4, 3

When infection is suspected or confirmed:

• Use broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis 3
• Preferred agents include carbapenems (meropenem 1g q6h by extended infusion, imipenem/cilastatin 500mg q6h), or quinolones with metronidazole 5, 3
• Routine antifungal agents are not recommended 3
• CT-guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases 3

Specialist Referral Criteria

Patients with >30% pancreatic necrosis should prompt discussion with or referral to a specialist unit. 5, 2 A specialist unit must include:

• A multidisciplinary team of specialists in surgery, endoscopy, intensive care, anaesthesia, gastroenterology, and nutrition 5
• Facilities for HDU/ITU management with renal and respiratory support 5
• Radiological expertise for dynamic CT, percutaneous drainage procedures 5
• Facilities for ERCP and therapeutic endoscopy on an emergency basis 5

Special Considerations

For disconnected pancreatic duct syndrome with walled-off necrosis, a single-stage surgical transgastric necrosectomy may be an option in selected cases. 1, 2, 4 For patients with disconnected left pancreatic remnant after mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in operative candidates. 3

For biliary pancreatitis, definitive treatment of gallstones (cholecystectomy) should not be delayed more than two weeks after discharge, but should be delayed in severe cases until signs of lung injury and systemic disturbance have resolved. 1

Common Pitfalls to Avoid

• Never intervene early (within first 2 weeks) unless absolutely necessary, as this significantly increases mortality 1, 2, 4
• Do not use size alone as a criterion for intervention 1
• Avoid over-resuscitation leading to abdominal compartment syndrome 1, 4
• Do not rely solely on percutaneous drainage for definitive treatment of solid necrotic tissue, as success rates are limited (14-32% cure rate) 1, 2
• Do not use prophylactic antibiotics in sterile necrosis 1, 4, 3