Digestive Diseases and Sciences

, Volume 59, Issue 9, pp 2069–2075 | Cite as

Getting the Dead Out: Modern Treatment Strategies for Necrotizing Pancreatitis

  • Monica M. Dua
  • David J. Worhunsky
  • Sabina Amin
  • John D. Louie
  • Walter G. Park
  • George Triadafilopoulos
  • Brendan C. VisserEmail author
Stanford Multidisciplinary Seminars

Case Presentation and Evolution

A 21-year-old male was brought to the emergency department with severe abdominal pain and vomiting. Low-grade fever and epigastric tenderness were noted on examination; laboratory values included a WBC of 11 K/μL and elevated amylase and lipase to 1,593 and >3,000 U/L, respectively. A CT scan was interpreted as showing an enlarged and ill-defined pancreas with heterogeneous parenchymal enhancement, consistent with pancreatitis. Several peripancreatic fluid collections extended bilaterally to the para-renal spaces, left para-colic gutter, and pelvis (Fig.  1). An ultrasound of the gallbladder was normal with no gallstones visualized. The patient had no other contributory past medical or social history. He was admitted to the medical service and initially developed a systemic inflammatory response (SIRS) to his idiopathic pancreatitis, with fever, tachycardia, and a white count peak to 16 K/μL. After several days of intravenous fluid resuscitation and...


Pancreatitis Acute Pancreatitis Pancreatic Necrosis Necrotizing Pancreatitis Infected Pancreatic Necrosis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor JA. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology. 2010;139:813–820.PubMedCrossRefGoogle Scholar
  2. 2.
    Fisher JM, Gardner TB. The “golden hours” of management in acute pancreatitis. Am J Gastroenterol. 2012;107:1146–1150.PubMedCrossRefGoogle Scholar
  3. 3.
    van Santvoort HC, Bakker OJ, Bollen TL, et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology. 2011;141:1254–1263.PubMedCrossRefGoogle Scholar
  4. 4.
    Rodriguez JR, Razo AO, Targarona J, et al. Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg. 2008;247:294–299.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Sleeman D, Levi DM, Cheung MC, et al. Percutaneous lavage as primary treatment for infected pancreatic necrosis. J Am Coll Surg. 2011;212:748–752; discussion 752–744.Google Scholar
  6. 6.
    van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362:1491–1502.PubMedCrossRefGoogle Scholar
  7. 7.
    Bakker OJ, van Santvoort HC, van Brunschot S, et al. Endoscopic transgastric necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012;307:1053–1061.PubMedCrossRefGoogle Scholar
  8. 8.
    Parekh D. Laparoscopic-assisted pancreatic necrosectomy: a new surgical option for treatment of severe necrotizing pancreatitis. Arch Surg. 2006;141:895–902; discussion 902–893.Google Scholar
  9. 9.
    Gibson SC, Robertson BF, Dickson EJ, McKay CJ, Carter CR. ‘Step-port’ laparoscopic cystgastrostomy for the management of organized solid predominant post-acute fluid collections after severe acute pancreatitis. HPB (Oxf). 2014;16:170–176.CrossRefGoogle Scholar
  10. 10.
    van Santvoort HC, Besselink MG, Horvath KD, et al. Videoscopic assisted retroperitoneal debridement in infected necrotizing pancreatitis. HPB (Oxf). 2007;9:156–159.CrossRefGoogle Scholar
  11. 11.
    Raraty MG, Halloran CM, Dodd S, et al. Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg. 2010;251:787–793.PubMedCrossRefGoogle Scholar
  12. 12.
    Freeman ML, Werner J, van Santvoort HC, et al. Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference. Pancreas. 2012;41:1176–1194.PubMedCrossRefGoogle Scholar
  13. 13.
    Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62:102–111.PubMedCrossRefGoogle Scholar
  14. 14.
    Fisher JM, Gardner TB. Endoscopic therapy of necrotizing pancreatitis and pseudocysts. Gastrointest Endosc Clin N Am. 2013;23:787–802.PubMedCrossRefGoogle Scholar
  15. 15.
    Pelaez-Luna M, Vege SS, Petersen BT, et al. Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases. Gastrointest Endosc. 2008;68:91–97.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Monica M. Dua
    • 1
  • David J. Worhunsky
    • 1
  • Sabina Amin
    • 2
  • John D. Louie
    • 2
  • Walter G. Park
    • 3
  • George Triadafilopoulos
    • 3
  • Brendan C. Visser
    • 1
    Email author
  1. 1.Division of Surgical Oncology, Department of SurgeryStanford University Medical CenterStanfordUSA
  2. 2.Department of RadiologyStanford University Medical CenterStanfordUSA
  3. 3.Department of MedicineStanford University Medical CenterStanfordUSA

Personalised recommendations