Pancreatic Necrosis and Pancreatic Abscess Treatment & Management
- Author: Abraham Mathew, MD, MS; Chief Editor: BS Anand, MD more...
In the acute phase of pancreatitis, the medical care of patients with evidence of pancreatic necrosis is no different from that of those without necrosis. Intravenous hydration aimed at maintaining the patient's intravascular volume and perfusion pressures is the mainstay of treatment of any cases of acute pancreatitis.
The 2013 American College of Gastroenterology (ACG) guidelines include the following recommendations for the initial management of acute pancreatitis :
Administer aggressive hydration, defined as the administration of isotonic crystalloid solution at a rate of 250–500 mL per hour, except in patients with cardiovascular, renal, or other related comorbidities. The greatest benefit of aggressive intravenous hydration is in the first 12–24 hours, but there may be little benefit beyond this period.
In patients with severe volume depletion presenting as hypotension and tachycardia, it may be necessary to administer a bolus.
Lactated Ringer solution may be the preferred isotonic crystalloid replacement fluid.
Frequently reassess fluid requirements within 6 hours of admission and for the next 24–48 hours with the goal of reducing blood urea nitrogen levels.
Moreover, the ACR recommends the following for antimicrobial/antifungal management of acute pancreatitis :
The routine use of prophylactic antibiotics and the routine use of antifungal agents along with prophylactic or therapeutic antibiotics in patients with severe acute pancreatitis is not recommended. In addition, it is not recommended to use antibiotics in patients with sterile necrosis to prevent infected necrosis.
Administer antibiotics for extrapancreatic infections (eg, cholangitis, catheter-acquired infections, bacteremia, urinary tract infections, pneumonia).
Consider infected necrosis in patients with pancreatic or extrapancreatic necrosis whose condition deteriorates or who fail to improve after 7–10 days of hospitalization. Obtain initial CT-guided fine-needle aspiration (FNA) for Gram stain and culture, or administer empiric antibiotic therapy after obtaining cultures for infectious agents, without CT FNA.
In patients with infected necrosis, administer antibiotics known to penetrate pancreatic necrosis (eg, carbapenems, quinolones, metronidazole), which may delay or avoid intervention, thereby decreasing morbidity and mortality.
Obtain consultations with a gastroenterologist, general surgeon, and interventional radiologist.
Patients usually should be in an ICU setting because they may decompensate quickly and require aggressive treatment, including mechanical ventilation.
A paradigm shift is occurring in the treatment of pancreatic necrosis and peripancreatic infections. In most tertiary care centers, open surgical procedures are being replaced by endoscopic or percutaneous procedures. Surgery is now reserved for cases in which an endoscopic or percutaneous approach is not feasible (ie, infection of the pancreatic bed before a well-formed, walled-off collection is formed; abdominal compartment syndromes). Open procedures, especially early on, carry significant mortality and morbidity and should be delayed until the patient's clinical situation is stable.
Transluminal drainage/necrosectomy by NOTES (natural orifice transluminal endoscopic surgery) approach is evolving as the preferred strategy for the management of pancreatic necrosis and abscesses. This procedure is ideally performed under endoscopic ultrasonographic (EUS) guidance.
EUS-guided necrosectomy in specialized centers is the standard treatment for pancreatic necrosis and abscess. CT-guided drainage is the next best strategy when a good transluminal window is not available for EUS-guided transgastric drainage, if the need for drainage is very early in the course of pancreatitis, or if the patient is too sick to undergo an endoscopic procedure, which often requires at least deep sedation.
Under EUS, an ideal site for access into the peripancreatic collection is identified. An area of adherence of the wall of the stomach or the intestine to the wall of the WOPN or infected pseudocyst is required. Endoscopic access is best performed when the wall is mature, usually 4 weeks or more after the episode of pancreatitis. An endoscopic transgastric access can be created even as early as 2 weeks following pancreatitis, but intervention other than placement of stents may be high risk, with the possibility of dehiscence into the peritoneum.
If a mature collection is accessed by EUS, a cystgastrostomy is created by dilating a tract up to 20 mm over a wire passed into the collection usually via a 19-gauge needle. This is accomplished with a wire-guided dilating balloon.
Once a large enough cystgastrostomy is made, a regular upper endoscope can be passed under direct vision into the necrotic or abscess cavity. The cavity is then debrided if necrotic material is present. The necrosum is pulled back and either removed or discarded in the gut lumen. At the end of the necrosectomy, two double pigtail stents are placed to prevent premature closure and to allow further drainage. Note that not removing the transmural stents decreases the recurrence of pancreatic fluid collection.
Complete necrosectomy may be accomplished in one or more sessions on the basis of the available time, amount of necrosum and ease of necrosectomy. One or more cystgastrostomies can be made for multiple gateways.
The most recent technique is that of placing a transluminal fully covered metal stent, which is specifically designed to be stationed across the cystgastrostomy and maintains a wide opening to allow drainage, with or without necrosectomy.
Endoscopic intervention leads to immediate symptomatic relief, especially abdominal pain caused by a tense or infected collection.[6, 8, 9]
A Dutch randomized trial has evaluated minimally invasive techniques for infected pancreatic necrosis and favors their use. The endoscopic approach results in lower morbidity rates, a faster recovery, and a shorter hospital stay.
If the interventionalist does not complete the necrosectomy, additional intervention may be needed. In earlier studies, sterile or infected walled-off pancreatic necrosis with transoral/transmural endoscopic drainage required percutaneous drainage in 40% of cases or operative intervention in 20%.[12, 13, 14] In 2015, primary drainage involving an open procedure should be avoided, if at all possible.
Minimally invasive alternatives for endoscopic drainage
Percutaneous drainage followed by percutaneous or sinus tract endoscopy with necrosectomy is an option and a potential minimally invasive alternative for endoscopic drainage, but there may be an associated higher risk of forming a pancreaticocutaneous fistula.
Alternative minimally invasive approaches include retroperitoneal laparoscopic necrosectomy and drainage, in which the entire necrosectomy is performed via percutaneous access without entry into the abdominal cavity.
Another surgical strategy involves establishing percutaneous access into the stomach using a laparoscopic approach and then performing a laparoscopic transgastric necrosectomy using rigid devices.
Even in the setting of infection, perform medical management with antibiotics and delay any surgical intervention as much as possible.
An ERCP is needed in most patients with pancreatic necrosis to evaluate and establish continuity of the pancreatic duct if there is ductal discontinuity. Endoscopic sphincterotomy plays a role in patients with gallstone pancreatitis, as well as for those with infected pancreatic necrosis, pancreatic abscess, pseudocysts, and traumatic pancreatitis with a ruptured duct system.
The 2013 American College of Gastroenterology (ACR) guidelines include the following recommendations regarding nutritional management for patients with acute pancreatitis :
For patients with mild disease, start oral feedings immediately in the absence of nausea/vomiting and with the resolution of abdominal pain. A low-fat solid diet appears to be as safe as a clear liquid diet.
For patients with severe pancreatitis, use enteral nutrition to prevent infectious complications. Avoid parenteral nutrition unless the enteral route is not available, is not tolerated, or caloric requirements are not being met.
Nasogastric delivery and nasojejunal delivery of enteral feeding appear to be equally safe and effective.
Patients generally are hospitalized and unable to perform usual activities.
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