What is the treatment for a patient with necrotizing pancreatitis?

Treatment of Necrotizing Pancreatitis

The optimal treatment of necrotizing pancreatitis requires a step-up approach with delayed intervention: initial intensive supportive care, percutaneous or endoscopic drainage as first-line treatment for infected necrosis, and minimally invasive debridement only when drainage fails—with surgical intervention postponed for at least 4 weeks after disease onset. 1, 2

Initial Management in ICU Setting

All patients with necrotizing pancreatitis must be managed in a high dependency unit or intensive care unit with full monitoring and systems support. 1, 3

Fluid Resuscitation and Physiological Support

• Provide adequate fluid resuscitation while avoiding over-resuscitation, which can lead to abdominal compartment syndrome 1, 2
• Necrotizing pancreatitis is not primarily a surgical disease in the early phase—treatment focuses on physiological support 1, 3

Nutrition Strategy

• Initiate early enteral nutrition rather than parenteral nutrition to decrease the risk of infected necrosis 1, 4
• Trial oral nutrition immediately if the patient has no nausea, vomiting, or severe ileus 4
• Use nasogastric/duodenal or nasojejunal tube feeding when oral intake is not feasible 4
• Reserve total parenteral nutrition only when enteral routes are not tolerated 4

Antibiotic Management

• Avoid prophylactic antibiotics in sterile pancreatic necrosis—reserve antibiotic therapy only for cases with signs/symptoms of infection 1, 3, 4
• When infected necrosis is suspected, use broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis (carbapenems, quinolones, metronidazole) 4
• Routine antifungal prophylaxis is not recommended 4

Pain Management

• Prioritize pain control, with dilaudid preferred over morphine or fentanyl in non-intubated patients 1

Diagnosis of Infected Necrosis

• 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 1, 3
• CT scan using a dedicated pancreas protocol is indicated for patients with persisting organ failure, signs of sepsis, or deterioration in clinical status 6-10 days after admission 3
• Suspect infected necrosis with fever, leukocytosis, organ failure, gas in the collection on imaging, bacteremia, or sepsis 4, 5

The 3D Approach: Delay, Drain, Debride

Delay: Timing is Critical

Postpone surgical interventions for at least 4 weeks after disease onset, which significantly reduces mortality. 1, 2, 4

• Delayed intervention allows better demarcation between necrotic and viable tissue, resulting in less bleeding and more effective necrosectomy 1, 2
• Avoid debridement in the early acute period (first 2 weeks) as it is associated with increased morbidity and mortality 4, 6
• Perform debridement earlier than 4 weeks only when there is an organized collection and a strong indication 4

Drain: First-Line Intervention

In infected pancreatic necrosis, percutaneous or endoscopic drainage is recommended as the first line of treatment (step-up approach). 1, 2, 4

Percutaneous Drainage

• Can completely resolve infection in 25-60% of patients without requiring further surgical intervention 1, 2
• Appropriate for collections in the early acute period (<2 weeks) or those with deep extension into paracolic gutters 3, 4
• Should be strongly considered as adjunct to endoscopic drainage for WON with deep extension into paracolic gutters and pelvis 4
• Allows delaying any subsequent surgical intervention to a more favorable time 2

Endoscopic Drainage

• Endoscopic ultrasound (EUS)-guided cystogastrostomy is preferred for central collections abutting the stomach 1, 3
• Endoscopic therapy through transmural drainage may be preferred as it avoids the risk of forming a pancreatocutaneous fistula 4
• Self-expanding metal stents (lumen-apposing metal stents) appear superior to plastic stents for endoscopic transmural drainage of necrosis 4
• Endoscopic drainage is associated with shorter hospital stays and better patient-reported mental and physical outcomes compared to surgical approaches 3

Debride: When Drainage Fails

When drainage is insufficient, minimally invasive surgical strategies should be employed. 1, 2

Direct Endoscopic Necrosectomy

• Reserve for patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore stents alone 4
• Can be used for patients with large amounts of infected necrosis, but should be performed at referral centers with necessary expertise 4

Minimally Invasive Surgical Approaches

• Minimally invasive approaches are preferred to open surgical necrosectomy when possible, given lower morbidity 4, 6
• Options include video-assisted retroperitoneal debridement (VARD), laparoscopic transgastric debridement, and minimally invasive retroperitoneal pancreatectomy 1, 7, 4
• These strategies result in less new-onset organ failure compared to open surgery, though they may require more interventions 2

Open Necrosectomy

• Reserved for cases refractory to all other approaches or not amenable to less invasive procedures 1, 4
• Thorough debridement of all necrotic tissue is essential 1, 3
• Following debridement, the abdomen may be closed over drains, packed and left open, or closed over drains with pancreatic cavity irrigation 3

Indications for Intervention

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

Management of Specific Complications

Biliary Pancreatitis

• For biliary pancreatitis with cholangitis, perform urgent endoscopic sphincterotomy or duct drainage by stenting to relieve biliary obstruction 1
• Perform definitive treatment of gallstones (cholecystectomy) within two weeks after discharge to prevent potentially fatal recurrent acute pancreatitis 1, 3
• Delay cholecystectomy in severe acute pancreatitis until signs of lung injury and systemic disturbance have resolved 1, 3

Disconnected Pancreatic Duct

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

Abdominal Compartment Syndrome

• For abdominal compartment syndrome unresponsive to conservative management, surgical decompression may be necessary 1, 2
• Do not perform emergency necrosectomy during early surgery for abdominal compartment syndrome or bowel necrosis 1, 2

Critical Pitfalls to Avoid

• Early surgical intervention (within first 2 weeks) significantly increases mortality and must be avoided 1, 2, 4
• Over-resuscitation can lead to abdominal compartment syndrome 1, 2
• Size alone should not be the criterion for intervention 1, 3
• Percutaneous drainage alone has limited success (14-32% cure rate) for definitive treatment of necrotic collections 1, 3, 2
• Do not rely solely on percutaneous drainage for definitive treatment of solid necrotic tissue, as infected necrosis requires complete debridement of all necrotic material 2

Multidisciplinary Approach and Referral

• Management requires a multidisciplinary team including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition 4
• Management of patients with >30% pancreatic necrosis should prompt discussion with or referral to a specialist unit 2
• In situations where clinical expertise may be limited, transfer patients with significant pancreatic necrosis to an appropriate tertiary-care center 4