What is the treatment for acute necrotizing pancreatitis with significant peripancreatic necrotic fluid collection?

From the Guidelines

Treatment for acute necrotizing pancreatitis with significant peripancreatic necrotic fluid collection should prioritize a step-up approach, starting with percutaneous or endoscopic drainage, and delaying intervention for at least 4 weeks to allow encapsulation unless the patient deteriorates, as recommended by the 2019 WSES guidelines 1.

Key Considerations

• Initial management focuses on aggressive fluid resuscitation with crystalloids, pain control with opioid analgesics, and nutritional support.
• Early enteral nutrition via nasojejunal tube should be initiated within 48-72 hours if possible, to maintain gut barrier function and reduce infectious complications.
• Prophylactic antibiotics are not routinely recommended unless there is confirmed infection, and broad-spectrum antibiotics like meropenem or piperacillin-tazobactam should be administered for infected necrosis.
• Minimally invasive techniques like endoscopic transgastric necrosectomy or percutaneous catheter drainage should be attempted before considering open surgical necrosectomy.

Intervention Timing

• Intervention for necrotic collections should be delayed for at least 4 weeks to allow encapsulation, unless the patient deteriorates, as this approach has been shown to reduce mortality and improve outcomes 1.
• A step-up approach is preferred, starting with percutaneous or endoscopic drainage, and escalating to more invasive procedures only if necessary.

Ongoing Supportive Care

• Monitoring for organ failure, managing complications like pseudocysts or vascular complications, and preventing secondary infections are crucial components of ongoing supportive care.
• A multidisciplinary approach involving intensive care, nutritional support, and potentially interventional procedures is essential for optimal management of acute necrotizing pancreatitis with significant peripancreatic necrotic fluid collection 1.

From the Research

Treatment Options for Acute Necrotizing Pancreatitis

• The treatment of acute necrotizing pancreatitis with significant peripancreatic necrotic fluid collection involves a multidisciplinary approach, including fluid resuscitation, nutritional support, and broad-spectrum antibiotics for infected necrotic peripancreatic fluid collection (PFC) 2.
• Indications for further invasive interventions include infected necrotic PFC and/or persistent severe symptoms due to mass effect 2.
• Current clinical management algorithms favor endoscopic ultrasound (EUS)-guided drainage of PFCs, with percutaneous drainage indicated in cases of large collections or extension to the paracolic gutters 2.
• Dual modalities (percutaneous together with endoscopic drainage) have been shown to possess lower rates of pancreatic-cutaneous fistulas, shorter length of hospitalization, and less endoscopic interventions 2.

Role of Percutaneous Drainage

• Percutaneous drainage is a minimally invasive intervention that can help in drainage of infected collections, temporize sepsis, and improve outcomes in patients with acute necrotizing pancreatitis 3.
• Percutaneous drainage should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with walled-off pancreatic necrosis (WON) who are too ill to undergo endoscopic or surgical intervention 4.
• Percutaneous drainage can also be used as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden 4.

Endoscopic and Surgical Interventions

• Endoscopic transmural drainage is a preferred first-line, nonsurgical approach in managing patients with walled-off pancreatic necrosis (WON) 4.
• Direct endoscopic necrosectomy should be reserved for patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation 4.
• Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity 4.
• Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures 4.