Necrotizing Pancreatitis: Best Approaches

Abstract

In the United States approximately 290,000 patients develop acute pancreatitis annually. The revised Atlanta classification of acute pancreatitis stratifies patients with acute pancreatitis into mild, moderately severe, or severe categories, based on the presence of organ failure and the presence of local or systemic complications. Severe acute pancreatitis is divided into two clinical phases: an early vasoactive and a late septic phase. The vasoactive phase typically occurs during the first two weeks and is dominated by the consequences of SIRS. The second phase of the disease is characterized by infection of pancreatic necrosis and subsequent sepsis. Intravenous contrast-enhanced CT scanning is the preferred imaging test for identifying pancreatic necrosis. Pancreatic and peripancreatic necrosis may be sterile or infected. Sterile necrosis is best managed medically during the first 3–4 weeks. After this interval, if abdominal pain persists and prevents oral intake, debridement should be considered. In the setting of infected pancreatic and peripancreatic necrosis, the goal of intervention is to debride all necrotic infected tissue, drain infected fluid collections, and minimize the risk of technical complications, including bleeding and enteric fistula. These goals can be accomplished either operatively, endoscopically, percutaneously, or by a combination of all approaches. Operative intervention should be delayed for at least 4 weeks after the original presentation, due to the excessive mortality and morbidity from early operative debridement. The main complications associated with pancreatic necrosectomy include perioperative hemorrhage; pancreatic fistula and disconnected left pancreatic remnant; enteric fistulas (colon, duodenum, stomach); intestinal/gallbladder ischemia; and pancreatic endocrine and exocrine insufficiency.