What is the morbidity of necrotizing pancreatitis?

From the Guidelines

Necrotizing pancreatitis is associated with significant morbidity, including multiple organ complications, and requires a multidisciplinary approach for management. The morbidity of necrotizing pancreatitis can be substantial, with complications affecting multiple organ systems, including the development of systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome (ARDS), acute kidney injury, and shock 1. Approximately 20-30% of acute pancreatitis cases progress to necrotizing pancreatitis, with mortality rates ranging from 15-30% depending on the extent of necrosis and presence of infection.

Key Complications and Morbidities

• Infected pancreatic necrosis, which occurs in 30-70% of patients with necrotizing pancreatitis and significantly worsens outcomes 1
• Pancreatic fistulas, pseudocysts, abscesses, splenic vein thrombosis, and gastrointestinal bleeding
• Long-term sequelae, including exocrine pancreatic insufficiency in 30-40% of survivors, requiring enzyme supplementation, and endocrine insufficiency (diabetes) in 20-30% of cases

Management Approach

• Initial conservative treatment focusing on fluid resuscitation, pain control, and nutritional support
• Invasive interventions are generally delayed until necrosis becomes walled-off (typically 4 weeks after onset) unless there is clinical deterioration 1
• The step-up approach, beginning with percutaneous drainage before considering minimally invasive or open necrosectomy, has reduced procedure-related complications and improved survival compared to immediate surgical intervention 1

Considerations for Intervention

• Signs or strong suspicion of infected necrosis in a symptomatic patient requires intervention, although a small number of patients have been shown to recover with antibiotics only 1
• Interventions should be considered when organ dysfunctions persist for more than 4 weeks 1
• Walled off necrotic collections or pseudocysts may cause symptoms and/or mechanical obstruction and if they do not resolve when inflammation ceases, a step up approach is indicated 1

From the Research

Morbidity of Necrotizing Pancreatitis

• Necrotizing pancreatitis is associated with substantial morbidity and mortality, requiring a multidisciplinary approach for optimal management 2.
• The condition is characterized by significant morbidity, with mortality rates ranging from 15% to 30-39% in cases of infected necrosis 3.
• Morbidity rates for open surgical necrosectomy can be as high as 34-95%, highlighting the need for less invasive techniques 3.
• Early enteral feeds have been shown to improve outcomes compared to parenteral nutrition, reducing the risk of morbidity 4.
• Pancreatic necrosis is associated with a multitude of complications, including organ failure, infected necrosis, and long-term morbidity or mortality 4.

Management and Therapies

• The management of pancreatic necrosis has shifted away from open necrosectomy to less invasive techniques, such as percutaneous catheter drainage, per-oral endoscopic, laparoscopy, and rigid retroperitoneal videoscopy 3.
• A step-up approach, consisting of percutaneous drainage or endoscopic transmural drainage, followed by direct endoscopic necrosectomy, and then surgical debridement, is a reasonable approach to managing necrotizing pancreatitis 2.
• Current evidence suggests that delaying interventions for at least 4 weeks, draining as a first resort, and debriding recalcitrant tissue using minimally invasive techniques can promote postoperative recovery while reducing wound-related complications 5.
• Minimally invasive operative approaches to debridement are preferred to open surgical necrosectomy when possible, given lower morbidity 2.

Diagnosis and Treatment

• Diagnosis of pancreatic necrosis is aided by pancreas-protocol computed tomography or magnetic resonance imaging, ideally 72 hours after onset of symptoms 4.
• The extent of necrosis correlates well with the incidence of infected necrosis, organ failure, need for debridement, and morbidity and mortality 4.
• The role of antibiotics is determined by the presence of infected necrosis, with broad-spectrum intravenous antibiotics recommended for culture-proven infection or strong suspicion of infection 2.
• Interventional therapy should be guided by available resources and the principle of a minimally invasive approach 4.