Intervention in Necrotizing Pancreatitis: An Evidence-based Review of Surgical and Percutaneous Alternatives

Abstract

Interventional therapy in necrotizing pancreatitis is evolving. Efforts to modify or prevent pancreatic necrosis by intra-arterial infusion of antibiotics and antiproteases have been described. Moreover, traditional approaches to the surgical management of infected pancreatic necrosis are being challenged by a host of endoscopic and percutaneous techniques. While these approaches are potentially valuable additions to interventional therapy in necrotizing pancreatitis, few evidence-based studies are available to support their supplanting more traditional approaches at this time. Cooperative evidence-based multiinstitutional studies will be required to address the validity of these proposals.

Interventional Radiology for Necrotizing Pancreatitis

“…8,10,11,[15][16][17] In an early study of 34 patients, 47% were cured with percutaneous catheter drainage alone, while sepsis was controlled in 74%. 10 Another study reported a comparable overall success rate (49%) in 35 patients, with similar success rates between percutaneous drainage of sterile (50%) and infected (46%) necrotizing pancreatic collections.…”

Treatment of Pancreatic Abscess with Endoscopic Ultrasound-guided Placement of a Covered Metal Stent Following Failed Balloon Dilation and Endoscopic Necrosectomy

“…Pancreatic pseudocyst traditionally is treated surgically, but this approach is accompanied by a high morbidity (13%–53%) and mortality (6.2%–25%) 2345. An alternative nonsurgical treatment involves percutaneous drainage with a long catheter; however, the effectiveness of this approach is inconsistent even for the drainage of a non-contagious pancreatic pseudocyst 1213…”

Acute pancreatitis

“…169 Infected necrosis invariably requires drainage or removal of infected tissue and numerous approaches are described including percutaneous radiological drainage, endoscopic drainage, minimally invasive surgery and extensive open debridement. 170 Prevention of infected necrosis using prophylactic antibiotics in AP remains controversial and the results of relevant studies equivocal. 170,171 Extensive peripancreatic fluid collections, including early pseudocysts (fluid in the lesser sac) are common in SAP and require percutaneous drainage if large, expanding or complicated by infection, bleeding, bowel obstruction or biliary obstruction.…”

“…170 Prevention of infected necrosis using prophylactic antibiotics in AP remains controversial and the results of relevant studies equivocal. 170,171 Extensive peripancreatic fluid collections, including early pseudocysts (fluid in the lesser sac) are common in SAP and require percutaneous drainage if large, expanding or complicated by infection, bleeding, bowel obstruction or biliary obstruction. After several weeks, mature pseudocysts may form and most are effectively managed with endoscopic or surgical cystoenteric drainage procedures.…”