What is the treatment for a patient with necrotizing pancreatitis?

Treatment of Necrotizing Pancreatitis

The optimal treatment of necrotizing pancreatitis follows a "step-up" approach with three key principles: delay intervention for at least 4 weeks when possible, start with percutaneous or endoscopic drainage as first-line therapy, and reserve debridement (minimally invasive preferred) only when drainage fails. 1, 2, 3

Initial Management in ICU/HDU

• All patients with necrotizing pancreatitis require management in a high dependency unit or intensive care unit with full monitoring and physiological support, as this is not primarily a surgical disease in the early phase. 1, 4

• Aggressive fluid resuscitation is essential, but avoid over-resuscitation which can precipitate abdominal compartment syndrome requiring surgical decompression. 1, 2, 5

• Initiate early enteral nutrition immediately (oral if tolerated, otherwise nasogastric/duodenal or nasojejunal tube) to decrease the risk of infected necrosis; reserve total parenteral nutrition only when enteral feeding is not feasible. 1, 3

• Avoid prophylactic antibiotics in sterile pancreatic necrosis; reserve antibiotic therapy only for documented or strongly suspected infection (gas in collection, bacteremia, sepsis, clinical deterioration). 1, 4, 3

• When antibiotics are indicated, use broad-spectrum agents with pancreatic penetration (carbapenems, quinolones, metronidazole). 3

Diagnosis of Infected Necrosis

• Obtain CT scan with dedicated pancreas protocol for patients with persisting organ failure, signs of sepsis, or clinical deterioration 6-10 days after admission. 4

• Perform image-guided fine needle aspiration (FNA) for culture in patients with persistent symptoms and >30% pancreatic necrosis, or those with smaller areas of necrosis and clinical suspicion of sepsis, at 7-14 days after onset. 6, 4

• Clinical indicators of infection include fever, leukocytosis, elevated CRP/procalcitonin, organ failure, or protracted severe clinical course. 7

The 3D Approach: Delay, Drain, Debride

Delay (Critical First Step)

• Postpone any intervention for at least 4 weeks after disease onset to allow demarcation between necrotic and viable tissue, which significantly reduces mortality and bleeding during subsequent procedures. 1, 2, 3

• Avoid debridement in the first 2 weeks, as early surgical intervention dramatically increases morbidity and mortality. 1, 2, 3

• Perform earlier intervention (but still delayed when possible) only when there is an organized collection with a strong indication. 3

Drain (First-Line Intervention)

For infected pancreatic necrosis, percutaneous drainage or endoscopic transmural drainage is the recommended first-line treatment. 1, 2, 3

Percutaneous Drainage

• Use percutaneous drainage for: collections in the early acute period (<2 weeks), patients too ill for endoscopic/surgical intervention, collections with deep extension into paracolic gutters and pelvis, or as adjunct to endoscopic drainage. 4, 3

• Percutaneous drainage completely resolves infection in 25-60% of patients without requiring further surgical intervention. 1, 2

• Recognize that percutaneous drainage alone has limited success (14-32% cure rate) for definitive treatment of solid necrotic tissue, as it may not achieve complete debridement. 1, 2

Endoscopic Drainage

• Endoscopic ultrasound (EUS)-guided cystogastrostomy is preferred for central collections abutting the stomach, as it avoids pancreatocutaneous fistula formation. 1, 4, 3

• Use lumen-apposing metal stents (LAMS), which are superior to plastic stents for endoscopic transmural drainage of necrosis. 3

• Endoscopic drainage is associated with shorter hospital stays and better patient-reported mental and physical outcomes compared to surgical approaches. 4

Debride (When Drainage Fails)

When percutaneous or endoscopic drainage is insufficient, employ minimally invasive surgical strategies before considering open surgery. 1, 2, 3

Direct Endoscopic Necrosectomy (DEN)

• Reserve direct endoscopic necrosectomy for patients with limited necrosis who do not respond to drainage with LAMS alone or plastic stents with irrigation. 3

• DEN is an option for large amounts of infected necrosis but should only be performed at referral centers with necessary expertise and surgical backup. 3

Minimally Invasive Surgery

• Minimally invasive approaches include video-assisted retroperitoneal debridement (VARD) and transgastric endoscopic necrosectomy, which result in less new-onset organ failure compared to open surgery, though they may require more interventions. 1, 2, 3

• Multiple minimally invasive surgical techniques are feasible: videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. 3

Open Surgical Necrosectomy

• Open operative debridement should be reserved for cases refractory to all other approaches or not amenable to less invasive procedures. 3, 8

• When performing open surgery, thorough debridement of all necrotic tissue is essential; the abdomen may be closed over drains, packed and left open, or closed over drains with pancreatic cavity irrigation (no clear superiority of one technique). 6, 4

Specific Indications for Intervention

Intervene for the following indications:

• Infected pancreatic necrosis (primary indication). 1
• Complications: gastric outlet obstruction, biliary obstruction, 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, nutritional failure, fistulas, or persistent SIRS. 3

Management of Biliary Pancreatitis

• For biliary pancreatitis with cholangitis, perform urgent endoscopic sphincterotomy or duct drainage by stenting to relieve biliary obstruction. 6

• Perform definitive treatment of gallstones (cholecystectomy) within two weeks after discharge to prevent potentially fatal recurrent acute pancreatitis; preferably during the same admission to avoid cancellation delays. 6, 1, 4

• Delay cholecystectomy in severe acute pancreatitis until signs of lung injury and systemic disturbance have resolved. 6, 1, 4

• For unfit patients, endoscopic sphincterotomy alone is adequate treatment. 6

Special Considerations

• For disconnected left pancreatic remnant after mid-body necrosis, perform definitive surgical management with distal pancreatectomy in patients with reasonable operative candidacy; insufficient evidence supports long-term transenteric endoscopic stenting. 3

• In selected cases with walled-off necrosis and disconnected pancreatic duct syndrome, single-stage surgical transgastric necrosectomy may be an option. 1, 2

• Patients with >30% pancreatic necrosis should prompt discussion with or referral to a specialist tertiary-care center with multidisciplinary expertise. 2, 3

Critical Pitfalls to Avoid

• Never perform early surgical intervention within the first 2 weeks, as it significantly increases mortality. 1, 2, 3

• Do not perform emergency necrosectomy during early surgery for other indications such as abdominal compartment syndrome or bowel necrosis. 1, 2

• Avoid using size alone as the criterion for intervention. 1, 4

• Do not use routine prophylactic antifungal agents. 3

• Avoid CT-guided FNA for Gram stain and cultures in the majority of cases, as it is unnecessary. 3