From the Guidelines
The step-up approach for pancreatic abscess management begins with less invasive procedures before escalating to more aggressive interventions, as recommended by the 2019 WSES guidelines for the management of severe acute pancreatitis 1.
Initial Management
Initially, percutaneous catheter drainage should be attempted under CT or ultrasound guidance, with placement of one or more large-bore drains into the abscess cavity. This approach is supported by the 2019 WSES guidelines, which suggest that interventions for necrotizing pancreatitis should preferably be done when the necrosis has become walled-off, usually after 4 weeks after the onset of the disease 1.
- Broad-spectrum antibiotics such as piperacillin-tazobactam, meropenem, or a combination of ciprofloxacin plus metronidazole should be administered concurrently, typically for 7-14 days depending on clinical response.
- The use of percutaneous drainage is also supported by a report from the UK guidelines for the management of acute pancreatitis, which found a 31% primary success rate in patients with pancreatic abscess managed by percutaneous drainage 1.
Escalation of Care
If percutaneous drainage fails after 72 hours, the next step is minimally invasive retroperitoneal necrosectomy, which involves creating a tract to the abscess and removing necrotic tissue using endoscopic tools.
- Open surgical necrosectomy is reserved as a last resort when less invasive methods fail, typically performed 3-4 weeks after initial presentation to allow for demarcation of necrotic tissue.
- This step-up approach reduces complications compared to immediate surgical intervention, as it minimizes the inflammatory response and decreases the risk of new organ failure, bleeding, and fistula formation while addressing the infected pancreatic collection 1.
Key Considerations
- The decision to intervene should be based on the presence of signs or strong suspicion of infected necrosis in a symptomatic patient, as well as the presence of organ dysfunctions that persist for more than 4 weeks 1.
- A symptomatic disconnected pancreatic duct resulting in a peripancreatic collection is also an indication for intervention 1.
From the Research
Pancreatic Abscess Step Up Protocol
The step up protocol for pancreatic abscess involves a combination of percutaneous drainage, surgical intervention, and antibiotic therapy.
- The initial approach may involve percutaneous catheter drainage (PCD) for stabilization of septic patients, drainage of further abscesses after surgical intervention, or associated abscesses remote from the pancreas 2.
- Patients with pancreatic abscess <50mm in diameter may be initially treated by ultrasound-guided percutaneous needle aspiration (PNA), while those with abscess ≥50mm may be initially treated by ultrasound-guided PCD 3.
- Surgery may be planned only when there is no clinical improvement after the initial percutaneous treatment 3.
- The role of surgery and PCD are complementary, and the choice of treatment depends on the clinical profile and investigations performed 4.
Antibiotic Therapy
- Antibiotics should not be given early in the disease course, as most symptoms are due to the inflammatory response, not an infectious etiology 5.
- Antibiotics are indicated when CT scans indicate a pancreatic phlegmon, empirically in the case of severe pancreatitis associated with septic shock, or with documented fine-needle aspiration biopsy identification of bacteria 5.
- Infected pancreatic necrosis should be treated with carbapenems, as they can effectively penetrate pancreatic tissue 5.
Treatment Outcomes
- The overall mortality for pancreatic abscess can be as low as 9.5% with proper management 4.
- Percutaneous management can be successful in 83.3% of patients, with a mortality of 8.3% 4.
- Surgical therapy alone can be successful in 85.7% of patients, with a mortality of 14.2% 4.
- Treatment of pancreatic abscess with wide sump drainage appears more effective than local drainage, with a mortality of 26% compared to 75% 6.