Management Of Infected Pancreatic Necrosis Research Articles

Waterjet pulse lavage as a safe adjunct to video assisted retroperitoneal debridement in necrotising pancreatitis

BackgroundMinimally invasive surgical necrosectomy plays an important role in the management of infected pancreatic necrosis, with a goal of removing debris and debriding necrotic tissue. Pulse lavage is designed to simultaneously hydrostatically debride and remove the infected necrotic tissue with suction. It is also able to remove significant amounts of debris without traumatic manipulation of the necrotic tissue which may be adherent to surrounding tissue and can result in injury.Methods and resultsThe surgical technique of utilising a waterjet pulse lavage device during the minimally invasive necrosectomy is detailed. Sixteen patients being managed via a step-up approach underwent endoscopic necrosectomy via a radiologically placed drain tract. All sixteen patients were successfully managed endoscopically without conversion to open necrosectomy, and survived their admission. There were no complications associated with the use of the waterjet pulse lavage.ConclusionWaterjet pulse lavage is a useful adjunct in minimally invasive necrosectomy, which reduces the length of the necrosectomy procedure, and facilitates removal of necrotic tissue while minimising the risk of traumatising healthy tissue.

Infected pancreatic necrosis-Current trends in management.

Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, amajority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.

Delayed surgical step-up approach for management of infected pancreatic necrosis – is it Worth or Vain?

Delayed surgical step-up approach for management of infected pancreatic necrosis – is it Worth or Vain?

Evaluating the role of the Minimal Incision Retroperitoneal Necrosectomy (MIRN) in the management of infected pancreatic necrosis: Experience from a tertiary care center

BackgroundThe conventional open necrosectomy was associated with high mortality and morbidities like secondary organ failure, incisional hernia, enterocutaneous fistula, and external pancreatic fistula. In acute pancreatitis, collections are primarily confined to the retroperitoneal space. Hence, the retroperitoneal approach can be used to drain the collection and necrotic material. It benefits smaller incisions and better outcomes in terms of morbidity and mortality than the conventional open necrosectomy. This study primarily aims to describe the effects of minimal incision retroperitoneal necrosectomy versus conventional open necrosectomy for treating INP. Moreover, it provides evidence supporting the efficacy and safety of this method. MethodsA single-center retrospective study of the prospectively maintained database from April 2008 to December 2021. ResultsA total of 122 patients were included in the study. Seventy-eight patients had an open necrosectomy, 30 had a MIRN, and 14 had a VARD procedure. These three groups were comparable in demographic variables. Preoperative variables like APACHE II at presentation, Modified CTSI, percentage of necrosis, multi-organ failure, time to surgery, and need for preoperative ICU stay were comparable among the three groups. Postoperative mortality was low in the MIRN group{open 35.8 % vs. MIRN 20.5 % vs. VARD 35.7 %, p = 0.066}. The postoperative stay was also significantly low in the MIRN and VARD group {open 23.62 ± 16.61 vs. MIRN 11.77 ± 7.73, VARD 8.86 ± 2.98, p = 0.00}. No significant difference in re-intervention rate, postoperative bleeding, and enterocutaneous fistula. ConclusionMIRN is a simple and easy-to-adapt procedure for infected pancreatic necrosis in the appropriately selected patient group.

Decreasing use of pancreatic necrosectomy and NSQIP predictors of complications and mortality

BackgroundSurgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery “step-up” approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the “step-up” approach.MethodsThe American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses.ResultsThere were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001).ConclusionSPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a “step-up” approach. Larger, prospective studies to compare indications and outcomes for “step up” versus open SPN are warranted.

Dynamics of Serum Procalcitonin Can Predict Outcome in Patients of Infected Pancreatic Necrosis: A Prospective Analysis.

Timely intervention can alter outcome in patients of infected pancreatic necrosis (IPN) but lacks adequate biomarker. Role of serum procalcitonin (PCT) in the management of IPN is understudied, and hence, this study was planned. All patients of acute pancreatitis with IPN without prior intervention were included. Baseline demographic, radiological and laboratory parameters were documented. PCT was measured at baseline, prior to intervention, and thereafter every 72h. Patients were grouped into those having baseline PCT < 1.0ng/mL and those with PCT ≥ 1.0ng/mL and various outcome measures werecompared. Of the 242 patients screened, 103 cases(66 males; 64.1%) with IPN were grouped into 2: PCT < 1.0ng/mL (n = 29) and PCT ≥ 1.0ng/mL (n = 74). Patients with baseline PCT ≥ 1.0ng/mL had significantly more severe disease scores. 16 out of 19 patients with rise in PCT on day-7 post-intervention expired. PCT ≥ 1.0ng/mL group had higher need for ICU (p = 0.001) and mortality (p = 0.044). PCT > 2.25ng/mL (aOR 22.56; p = 0.013)at baseline and failure in reduction of PCT levels to < 60% of baseline at day-7 post-intervention (aOR 53.76; p = 0.001) were significant mortality predictors. Baseline PCT > 1.0ng/mL is associated with poor outcome. PCT > 2.25ng/mL and failure in reduction of PCT levels to < 60% of its baseline at day-7 post-intervention can identify high-mortality risk patients.

A Step-up Approach for the Management of Infected Pancreatic Necrosis

Acute pancreatitis (AP) is an acute inflammation of the pancreas. Many of the mild AP and moderately severe AP (SAP) are self-limiting with a good prognosis, but the management of 15%–20% of SAP is very difficult and results in a mortality rate of 36%–50%. It poses a great challenge in clinical diagnosis and treatment. Infected pancreatic necrosis develops in approximately 20% to 30% of patients with AP, which is treated with the use of a step-up approach, with catheter drainage often delayed until the infected necrosis is encapsulated.

Percutaneous direct endoscopic pancreatic necrosectomy.

Approximately 10%-20% of the cases of acute pancreatitis have acute necrotizing pancreatitis. The infection of pancreatic necrosis is typically associated with a prolonged course and poor prognosis. The multidisciplinary, minimally invasive “step-up” approach is the cornerstone of the management of infected pancreatic necrosis (IPN). Endosonography-guided transmural drainage and debridement is the preferred and minimally invasive technique for those with IPN. However, it is technically not feasible in patients with early pancreatic/peripancreatic fluid collections (PFC) (< 2-4 wk) where the wall has not formed; in PFC in paracolic gutters/pelvis; or in walled off pancreatic necrosis (WOPN) distant from the stomach/duodenum. Percutaneous drainage of these infected PFC or WOPN provides rapid infection control and patient stabilization. In a subset of patients where sepsis persists and necrosectomy is needed, the sinus drain tract between WOPN and skin-established after percutaneous drainage or surgical necrosectomy drain, can be used for percutaneous direct endoscopic necrosectomy (PDEN). There have been technical advances in PDEN over the last two decades. An esophageal fully covered self-expandable metal stent, like the lumen-apposing metal stent used in transmural direct endoscopic necrosectomy, keeps the drainage tract patent and allows easy and multiple passes of the flexible endoscope while performing PDEN. There are several advantages to the PDEN procedure. In expert hands, PDEN appears to be an effective, safe, and minimally invasive adjunct to the management of IPN and may particularly be considered when a conventional drain is in situ by virtue of previous percutaneous or surgical intervention. In this current review, we summarize the indications, techniques, advantages, and disadvantages of PDEN. In addition, we describe two cases of PDEN in distinct clinical situations, followed by a review of the most recent literature.

The clinical outcome from early versus delayed minimally invasive intervention for infected pancreatic necrosis: a systematic review and meta-analysis.

While the management of infected pancreatic necrosis (IPN) has evolved in the last two decades with the adoption of minimally invasive interventions (drainage ± debridement), it is unknown whether the principle of delaying intervention inherited from the open surgery era still applies. The aim of the current study was to investigate the impact of the timing of minimally invasive intervention on the outcomes of patients with IPN requiring intervention. PubMed, Embase, MEDLINE and Web of Science databases were searched for appropriate studies. The primary outcome of interest was hospital mortality, the secondary outcomes were the incidence of complications during the hospitalization, including new-onset organ failure, gastrointestinal fistula or perforation, bleeding and length of hospital or intensive care unit (ICU) stay. Seven clinical studies were included with a total of 742 patients with IPN requiring intervention, of whom 321 received early intervention and 421 delayed intervention. Results from the meta-analysis showed that early minimally invasive intervention did not increase hospital mortality (odds ratio 1.65, 95% confidence interval 0.97-2.81; p = 0.06) but was associated with a remarkably prolonged hospital stay and an increased incidence of gastrointestinal fistula or perforation when compared with delayed intervention. Although no firm conclusion can be drawn because of the quality of available studies, it does appear that timing of intervention is a risk factor for adverse outcomes and ought to be investigated more rigorously in prospective studies.

The Step up Approach in the Management of Infected Pancreatic Necrosis: A Case Report

Approximately 15% of patients with acute pancreatitis develop the severe form. Treatment of infected necrotizing pancreatitis has changed over the past 20 years and continues to evolve with increasing experience, new techniques, and research. The “Step Up Approach” consists of the successive placement of drains of progressively greater caliber, it has demonstrated, since the publication of the PANTER study, its superiority over the classical surgical approach in terms of morbidity. In up to 35% of cases, the episode will be resolved only in this way, in the rest of patients, the pancreatic cell will be debrided. We present the case of a patient with a diagnosis of severe acute pancreatitis and infected pancreatic necrosis who was managed with the now popular “step up” approach 28-year-old male with dyslipidemic origin, with necrosis pancreatic, peripancreatic collections, and gas in retroperitoneum, treated with TPN, pancreatin (CREON) and antibiotic therapy (Imipenem). He developed infected necrosis that required drainage with two 12 Fr and 14 Fr pigtails (25th day-hospitalization), with ultrasound-guided access in the right flank and left flank. Catheter replacement and progressive increase in diameter were performed, followed by RPVA necrosectomy following the path of the left pigtail (th day-hospitalization). The evolution was favorable, with progressive withdrawal of drains, and discharge without drains on day 65 of hospitalization. The "Step Up Approach" is the current standard in the treatment of infected pancreatic necrosis, it is effective and safe, avoiding the serious complications of open necrosectomy, with a good recovery of the patient.

Infected Pancreatic Necrosis: Our Management Approach

Management of infected Pancreatic necrosis caries a significant morbidity and mortality. With percutaneous and endoscopic modalities reducing the need for operative intervention, a surgeon is still called when the liquid component is drained while solid component causes ongoing sepsis (despite upsizing). Here we present our management approach to this vexing problem. We divide the abdominal cavity containing necrotic material into (CECT scan based), Type 1 Central collection with or without gas Type 2 Paracolic gutter collectiona)Rightb)Left Type 3 Central collection witha)Right Paracolic gutter collectionb)Left Paracolic gutter collection Type 4 Central collection with both Paracolic gutter involvement. (Butterfly pattern) Type 5 Generalized peritonitis. Central collection is drained using Laparoscopic Transmesocolic approach while Paracolic gutter collection are dealt with Extra Peritoneal approach ( Modified VARD). Laparoscopic transmesocolic approach involves removal of solid and liquid necrotic material and placement of large bore drainage tubes for irrigation under direct vision. Extra peritoneal approach is using 5 cm incision in either flank and removal of necrotic material under vision using laparoscope. After the material is removed a drain is placed. Type 1(laparoscopic only) type 2(modified vard) has the best prognosis while type 3 is done using both techniques in a staged or simultaneous manner, type 4 and 5 has high morbidity and mortality. If a previous percutaneous drain is placed we use it as irrigation drain. This strategy simplifies the management in a minimally invasive way with good results.

Current management of infected pancreatic necrosis in a referral center. should open necrosectomy be abandoned?

Current management of infected pancreatic necrosis in a referral center. should open necrosectomy be abandoned?

The step up approach in the management of infected pancreatic necrosis. A case report

Presenter: Maria Liz Sanchez MD | Hospital de Clínicas de Asunción Background: Approximately 15% of patients with acute pancreatitis (AP) develop the severe form. Treatment of infected necrotizing pancreatitis has changed over the past 20 years and continues to evolve with increasing experience, new techniques, and research. Treatment of Infected necrosis by laparotomy is associated with high morbidity and mortality. The “Step Up Approach” consists of the successive placement of drains of progressively greater caliber, it has demonstrated, since the publication of the PANTER study, its superiority over the classical surgical approach in terms of morbidity. In up to 35% of cases, the episode will be resolved only in this way, in the rest of patients, the pancreatic cell will be debrided. Methods: We present the case of a patient with a diagnosis of severe acute pancreatitis and infected pancreatic necrosis who was managed with the now popular “step up” approach Results: Clinical case: 28-year-old male with dyslipidemic origin (AP), with necrosis pancreatic, peripancreatic collections, and gas in retroperitoneum, treated with TPN, pancreatin (CREON) and antibiotic therapy (Imipenem 20 days and then according to antibiogram). He developed infected necrosis that required drainage with two 12 Fr and 14 Fr pigtails (25th day-hospitalization), with ultrasound-guided access in the right flank and left flank. Catheter replacement and progressive increase in diameter were performed, followed by RPVA necrosectomy following the path of the left pigtail (th day-hospitalization). The evolution was favorable, with progressive withdrawal of drains, and discharge without drains on day 65 of hospitalization. Conclusion: The “Step Up Approach” is the current standard in the treatment of infected pancreatic necrosis, it is effective and safe, avoiding the serious complications of open necrosectomy, with a good recovery of the patient.

Novel techniques for management of portal system hemorrhage in acute pancreatitis

Current management of infected pancreatic necrosis is focused on a minimally invasive step-up approach. The step-up approach consists of initial percutaneous or endoscopic drainage of infected pancreatic necrosis, followed, if necessary, by minimally invasive surgical or endoscopic debridement. While there is reduced morbidity and mortality, vascular complications can be life-threatening. Reported vascular complications have been limited to arterial bleeding. Venous bleeding has not been previously reported. We present two cases of portal venous bleeding in patients who underwent treatment for infected pancreatic necrosis with a step-up approach. We discuss the clinical presentation, diagnosis, and initial management. Moreover, we present two different techniques that can be used to successfully manage venous bleeding in patients who have percutaneous drains in place as part of a step-up approach. These techniques involve tamponading the cavity or drain tract with topical hemostatics and direct embolization of the bleeding vein. These experiences can serve as a guide for managing portal venous bleeding in patients with infected pancreatic necrosis.

Predrainage and Postdrainage Prognostic Nomograms to Predict Outcome of Percutaneous Drainage for Infected Pancreatic and Peripancreatic Necrotic Collections.

This study aimed to identify factors affecting outcome of percutaneous catheter drainage (PCD) in management of infected pancreatic necrosis treated with step-up approach. This was a single-center retrospective cohort study that included patients with infected necrosis undergoing PCD as initial intervention. Patients who did not respond underwent necrosectomy. Predictors of PCD failure (ie, mortality or need for necrosectomy) were analyzed. Models were constructed for predrainage and postdrainage use and were internally validated. Of 304 patients included, catheter drainage was successful in 59.8%, with overall mortality of 22%. Predrainage model consisted of Acute Physiologic and Chronic Health Evaluation II score at admission, early organ failure, and pancreatic necrosis of greater than 50%. Postdrainage model consisted of Acute Physiologic and Chronic Health Evaluation II at first PCD, early organ failure, pancreatic necrosis of greater than 50%, sepsis reversal within 1 week of PCD and Escherichia coli in PCD culture. Both models were internally validated with area under receiver operating characteristics curve of 71.2% for pre-PCD and 81.2% for post-PCD model. Prognostic nomograms were constructed using the models. Percutaneous catheter drainage alone was successful in 59.8% with mortality of 22%. The nomograms can help in guiding treatment strategy and referral of high-risk cases.

Management of infected pancreatic necrosis: a single center experience

Acute pancreatitis is accompanied by acinar cell damage releasing potential toll-like receptor 3 (TLR3) ligands. So far, TLR3 is known as a pattern recognition receptor in the immune signaling cascade triggering a type I interferon response. In addition, TLR3 signaling contributes to programmed cell death through the activation of caspase 8. However, the functional role of TLR3 and its downstream toll-like receptor adaptor molecule 1 (TICAM1) in the inflamed pancreas is unknown.To uncover the role of TLR3 signaling in acute pancreatitis, we induced a cerulein-mediated pancreatitis in Tlr3 and Ticam1 knockout (KO) mice and in wildtype animals. The exocrine damage was determined by blood serum analysis and histological examination. Immunohistochemistry, gene expression and immunoblot analysis were conducted to study TLR3 function.After the induction of an acute pancreatitis, wildtype mice showed a high endosomal TLR3 expression in acinar cells. In comparison to wildtype and Ticam1 KO mice, Tlr3 KO mice exhibited the highest severity of pancreatitis with an increased NF-κB activation and elevated expression of the pro-inflammatory cytokines Il6 and Tnf, although the amount of infiltrating immune cells was unaffected. Additionally, we detected a strong elevation of acinar cell necrosis and reduced levels of cleaved caspase 8 in Tlr3 and Ticam1 KO mice.TLR3 and its downstream adaptor TICAM1 are important mediators of acinar cell damage in acute pancreatitis. They possess a critical role in programmed cell death and our data suggest that TLR3 signaling controls the onset and severity of acute pancreatitis.

A step-up drainage combined with thermostatic lavage in the management of infected pancreatic necrosis

Objective To investigate the safety and efficacy of a step-up drainage combined with thermostatic lavage in the management of severe acute pancreatitis complicated with infected pancreatic necrosis. Methods From January 2014 to July 2017, 100 cases of severe acute pancreatitis complicated with infected pancreatic necrosis admitted to our hospital were prospectively collected. All patients were randomly (random number) assigned into the observation group and control group with 50 cases in each group. The patients in both groups were given a step-up drainage. Moreover, patients in the observation group received lavage under constant temperature (30-35 °C) while the patients in the control group were at room temperature. The clinical prognosis of the two groups was observed. Results When compared with the control group, patients in the observation group got a lower rate of new onset renal injury (16.00% vs 34.00%, P=0.038); a lower rate of new onset gastrointestinal dysfunction (12.00% vs 28.00%, P=0.046); a reduced mechanical ventilation time[ (14.82±7.78)vs (18.64±8.12)d, P=0.018]; a decreased continuous blood filtration [(12.98±6.20) vs (18.56±10.92)d, P=0.002]; and a shorter hospital duration [(43.28±10.72) vs (50.82±12.74) d, P=0.002]. No significant difference was found in the APACHEⅡscore between the two groups at admission and at the time of puncture [(9.88±2.40) vs (9.46±2.35), P=0.378 and (10.30±3.07 vs (10.54±2.96), P=0.692]. At 7 and 14 days after the puncture, the APACHE II score in the observation group was significantly lower than that in the control group [(9.32±2.49) vs (10.56±2.80), P=0.021 and (6.20±2.54 vs (8.42±2.48), P<0.01]. Conclusions A step-up drainage combined with constant temperature lavage can reduce the incidence of new renal failure and gastrointestinal dysfunction in infected pancreatic necrosis patients and improve the clinical prognosis of the patients. Key words: Thermostatic lavage; Severe acute pancreatitis; Organ failure

Role of Ultrasound-Guided Percutaneous Catheter Drainage in the Management of Infected Pancreatic Necrosis

Background: Percutaneous catheter drainage has been widely accepted in infected necrotizing pancreatitis. Aims: We evaluated clinical safety and efficacy of ultrasound-guided percutaneous catheter drainage in patients with infected pancreatic necrosis. Subjects: Our prospective study included 44 patients who developed infection of peri/pancreatic necrosis. Of these patients, 25 cases received ultrasound-guided PCD study group) whereas 21 cases underwent surgery (control group). Intervention: On admission all patients were treated with fluid therapy, nutritional support, antibiotics, gastrointestinal decompression and analgesics. Ultrasound-guided PCD or surgery were performed in patients who suspected infection of necrotic collection. Conversion to surgery were considered in patients who failed to PCD. Clinical outcomes: primary outcomes were changes in laboratory parameters before and after treatment, recovery days of inflammatory parameters (WBC, CRP). Secondary outcomes were the incidence of complication, mortality and hospital stay. Results: In the study group PCD period was 30 (median) days (9-91, range). PCD was unsuccessful in 9 (36.0%) patients, who required eventually cross over to necrosectomy. All laboratory parameters (WBC, CRP, serum amylase, blood glucose, serum calcium) were improved after therapy compared to before therapy in both groups (p<0.05). The post treatment comparison showed the level of WBC, CRP, serum amylase and blood glucose in the study group were significantly lower than those in the control group (p<0.05). In PCD group recovery days of WBC, CRP was significantly decreased compared to control group (p<0.05). In study group incidence of new-onset organ failure, intra-abdominal bleeding and incisional hernia significantly reduced than those in the control group (p<0.05). Finally, the mortality rate in the study group was lower than control group and study group had shorter hospital stays compared to control group (p<0.05). Conclusion: Ultrasound-guided PCD can reduce the need of surgical treatment and step-up approach (PCD followed by surgery) may decrease mortality than primary necrosectomy by minimizing pancreatic injury.

AB001. 216. Pancreatic necrosectomy: a revised role in clinical practice

: The role of pancreatic necrosectomy has been revised substantially over the last two decades. While previously widely employed in the management of infected pancreatic necrosis, current practice emphasises the use of radiologically placed drains in the ‘Step-up’ approach as outlined in the PANTER trial. Pancreatic necrosectomy is still a viable treatment option in patients who fail to progress in spite of radiological management. We will present the case report of a 56-year-old gentleman admitted with alcohol induced pancreatitis who subsequently developed infected pancreatic necrosis. The patient was initially managed with the ‘step-up’ approach of radiological drainage, with frequent drain upsizing over the course of 3 weeks. In spite of this, adequate source control was not achieved, and the decision was made to progress to pancreatic necrosectomy. A good clinical outcome was achieved. With the aid of intra-operative video, the revised indications and process of open pancreatic necrosectomy will be outlined. The current literature will be discussed. Selective pancreatic necrosectomy remains an effective procedure in a small group of patients with infected pancreatic necrosis, who fail to progress in spite of optimum radiological management.

Managing Infected Pancreatic Necrosis.

The management of infected pancreatic necrosis has historically been based on early, open necrosectomy, associated with significant mortality. In recent years, an evidence based transformation has occurred towards the step-up approach consisting of percutaneous catheter drainage, if necessary, followed by minimally invasive necrosectomy. More recently the endoscopic step-up approach has gained popularity. This review evaluates the diagnosis, prevention and treatment of infected necrotizing pancreatitis. Key points in managing infected pancreatic necrosis: - multidisciplinary team approach in tertiary level centres; - no indication for prophylactic antibiotics or probiotics; - nasogastric, enteral nutrition indicated after 72 hours, if oral feeding is insufficient; - only intervene in infected necrosis; - delay intervention until "walled-off necrosis"; - step-up approach of percutaneous or endoscopic catheter drainage, followed by minimally invasive necrosectomy, if required; - endoscopic strategies are preferable where possible.