What is the best approach to manage a patient with acute necrotizing pancreatitis, considering their medical history, demographics, and nutritional status?

Management of Acute Necrotizing Pancreatitis

The Step-Up Approach: Delay, Drain, Debride

The optimal management of acute necrotizing pancreatitis requires a step-up approach with delayed intervention (≥4 weeks when possible), starting with percutaneous or endoscopic drainage, progressing to minimally invasive necrosectomy only if drainage fails, and should be coordinated by a multidisciplinary team at a specialized center. 1, 2

Initial Resuscitation and Monitoring

All patients with acute necrotizing pancreatitis must be managed in a high dependency unit (HDU) or intensive care unit (ICU) with comprehensive monitoring. 2, 3

• Establish continuous monitoring including hourly vital signs (pulse, blood pressure, respiratory rate, oxygen saturation, temperature), central venous pressure (CVP), and urine output 4, 2
• Monitor laboratory markers including hematocrit, blood urea nitrogen, creatinine, and lactate as indicators of tissue perfusion 2
• Provide goal-directed moderate fluid resuscitation using Lactated Ringer's solution, targeting urine output >0.5 mL/kg body weight 3
• Avoid aggressive fluid resuscitation protocols, as they increase mortality and complications without improving outcomes 2

Nutritional Support

Initiate early enteral nutrition within 24 hours via nasogastric or nasojejunal tube to prevent gut failure and infectious complications. 2

• Both gastric and jejunal feeding routes are safe and effective 2
• Reserve parenteral nutrition only for patients who cannot tolerate enteral nutrition or when enteral nutrition is contraindicated 2
• In patients with intra-abdominal pressure (IAP) <15 mmHg, start enteral nutrition via nasojejunal (preferred) or nasogastric tube 2
• For IAP >15 mmHg, initiate enteral nutrition via nasojejunal route starting at 20 mL/h with rate increases based on tolerance 2
• When IAP exceeds 20 mmHg or abdominal compartment syndrome develops, temporarily discontinue enteral nutrition and initiate parenteral nutrition 2

Antibiotic Management

Do not administer prophylactic antibiotics routinely, as they do not prevent infection of pancreatic necrosis. 2, 3

• Reserve antibiotics only for documented infections (infected necrosis, respiratory infections, urinary infections) 2, 3
• If antibiotic prophylaxis is used in severe pancreatitis with >30% pancreatic necrosis, limit duration to maximum 14 days 2, 3
• Intravenous cefuroxime represents a reasonable balance between efficacy and cost when antibiotics are indicated 3

Imaging Strategy

Obtain dynamic contrast-enhanced CT scanning within 3-10 days of admission using non-ionic contrast to assess extent of necrosis. 2

• Perform imaging only if clinical deterioration occurs 6-10 days after admission, looking for specific complications requiring intervention rather than routine scanning 3
• The extent of necrosis correlates with risk of tissue infection 5

The 3D Protocol: Delay, Drain, Debride

1. DELAY: Postpone Intervention

Postpone surgical interventions for at least 4 weeks after disease onset, as this significantly reduces mortality by allowing better demarcation between necrotic and viable tissue. 4, 1

• Delayed intervention results in less bleeding and more effective necrosectomy 1
• Early surgery (within first 2 weeks) significantly increases mortality 1
• The only exceptions for early intervention are: abdominal compartment syndrome unresponsive to conservative management, acute ongoing bleeding when endovascular approach fails, or bowel ischemia/acute necrotizing cholecystitis 4, 2

2. DRAIN: Percutaneous or Endoscopic Drainage First

In infected pancreatic necrosis, percutaneous or endoscopic drainage is the first-line treatment. 1, 6

• Percutaneous drainage can completely resolve infection in 25-60% of patients without requiring further surgical intervention 1
• Central collections abutting the stomach may be better approached with endoscopic transluminal drainage 1
• Collections in the tail of the pancreas or those not in direct communication with the pancreas may be better treated by percutaneous drainage 1
• Clinical deterioration with signs or strong suspicion of infected necrotizing pancreatitis is the primary indication to perform drainage 4, 3

3. DEBRIDE: Minimally Invasive Necrosectomy if Drainage Fails

When percutaneous or endoscopic drainage is insufficient, employ minimally invasive surgical strategies. 1, 6

• Minimally invasive approaches include video-assisted retroperitoneal debridement (VARD) and transgastric endoscopic necrosectomy 1, 6
• These minimally invasive strategies result in less new-onset organ failure and lower rates of pancreatic insufficiency compared to open surgery 1, 7
• Open necrosectomy should be considered only as salvage therapy for patients deteriorating despite other measures 5, 8

Indications for Intervention After 4 Weeks

After 4 weeks from disease onset, consider intervention for the following indications: 4

• Ongoing organ failure without signs of infected necrosis 4
• Ongoing gastric outlet, biliary, or intestinal obstruction due to large walled-off necrotic collection 4
• Disconnected duct syndrome 4
• Symptomatic or growing pseudocyst 4
• After 8 weeks: ongoing pain and/or discomfort 4

Special Considerations for Biliary Pancreatitis

Perform urgent therapeutic ERCP (within 24-72 hours) in patients with acute pancreatitis of suspected or proven gallstone etiology who have cholangitis, jaundice, or a dilated common bile duct. 2

• All patients with biliary pancreatitis should undergo definitive management of gallstones (cholecystectomy) during the same hospital admission, unless a clear plan has been made for definitive treatment within the next 2-4 weeks 2

Referral to Specialist Centers

Management in, or referral to, a specialist unit is necessary for patients with extensive necrotizing pancreatitis (>30% necrosis) or with complications requiring intensive care, interventional radiological, endoscopic, or surgical procedures. 4, 2

• Every hospital that receives acute admissions should have a single nominated clinical team to manage all patients with acute pancreatitis 4, 2
• A specialist unit should include a multidisciplinary team of specialists in surgery, endoscopy, intensive care, gastroenterology, nutrition, and interventional radiology 4

Critical Pitfalls to Avoid

• Never perform early surgical intervention (within first 2 weeks) as it significantly increases mortality 1
• Never perform emergency necrosectomy during early surgery for other indications such as abdominal compartment syndrome or bowel necrosis 3
• Avoid over-resuscitation which can lead to abdominal compartment syndrome 1, 2
• Do not rely solely on percutaneous drainage for definitive treatment of solid necrotic tissue, as success rates are limited 1
• Avoid prophylactic antibiotics as they do not prevent infection of pancreatic necrosis 2, 3

Expected Outcomes

• Overall mortality from necrotizing pancreatitis is 30-40%, with target mortality in specialist centers <30% 2
• Approximately one-third of deaths occur in the early phase from multiple organ failure, while most deaths after the first week are due to infected necrosis 2
• Specialist centers using the step-up approach have reported mortality rates between 10-20% 2
• Sterile necrosis has a mortality rate of 0-11% and typically does not require intervention 2