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Necrotizing pancreatitis: new definitions and a new era in surgical management.
Surg Infect (Larchmt). 2015 Feb; 16(1):1-13.SI

Abstract

BACKGROUND

Necrotizing pancreatitis is a challenging condition that requires surgical treatment commonly and is associated with substantial morbidity and mortality. Over the past decade, new definitions have been developed for standardization of severity of acute and necrotizing pancreatitis, and new management techniques have emerged based on prospective, randomized clinical trials.

METHODS

Review of English-language literature.

RESULTS

A new international classification of acute pancreatitis has been developed by PANCREA (Pancreatitis Across Nations Clinical Research and Education Alliance) to replace the Atlanta Classification. It is based on the actual local (whether pancreatic necrosis is present or not, whether it is sterile or infected) and systemic determinants (whether organ failure is present or not, whether it is transient or persistent) of severity. Early management requires goal-directed fluid resuscitation (with avoidance of over-resuscitation and abdominal compartment syndrome), assessment of severity of pancreatitis, diagnostic computed tomography (CT) imaging to assess for necrotizing pancreatitis, consideration of endoscopic retrograde cholangiopancreatography (ERCP) for biliary pancreatitis and early enteral nutrition support. Antibiotic prophylaxis is not recommended. Therapeutic antibiotics are required for treatment of documented infected pancreatic necrosis. The initial treatment of infected pancreatic necrosis is percutaneous catheter or endoscopic (transgastric/transduodenal) drainage with a second drain placement as required. Lack of clinical improvement after these initial procedures warrants consideration of minimally invasive techniques for pancreatic necrosectomy including video-assisted retroperitoneal debridement (VARD), minimally invasive retroperitoneal pancreatectomy (MIRP), or transluminal direct endoscopic necrosectomy (DEN). Open necrosectomy is associated with substantial morbidity, but to date no randomized trial has documented superiority of either minimally invasive or open surgical technique. Additional trials are underway to address this.

CONCLUSIONS

Severe acute and necrotizing pancreatitis requires a multi-disciplinary treatment strategy that must be individualized for each patient. Optimal treatment of necrotizing pancreatitis now requires a staged, multi-disciplinary, minimally invasive "step-up" approach that includes a team of interventional radiologists, therapeutic endoscopists, and surgeons.

Authors+Show Affiliations

Division of Acute Care Surgery [Trauma, Burn, Surgical Critical Care, Emergency Surgery], Department of Surgery, University of Michigan Medical Center , Ann Arbor, Michigan.No affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

25761075

Citation

Rosenberg, Andrew, et al. "Necrotizing Pancreatitis: New Definitions and a New Era in Surgical Management." Surgical Infections, vol. 16, no. 1, 2015, pp. 1-13.
Rosenberg A, Steensma EA, Napolitano LM. Necrotizing pancreatitis: new definitions and a new era in surgical management. Surg Infect (Larchmt). 2015;16(1):1-13.
Rosenberg, A., Steensma, E. A., & Napolitano, L. M. (2015). Necrotizing pancreatitis: new definitions and a new era in surgical management. Surgical Infections, 16(1), 1-13. https://doi.org/10.1089/sur.2014.123
Rosenberg A, Steensma EA, Napolitano LM. Necrotizing Pancreatitis: New Definitions and a New Era in Surgical Management. Surg Infect (Larchmt). 2015;16(1):1-13. PubMed PMID: 25761075.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Necrotizing pancreatitis: new definitions and a new era in surgical management. AU - Rosenberg,Andrew, AU - Steensma,Elizabeth A, AU - Napolitano,Lena M, PY - 2015/3/12/entrez PY - 2015/3/12/pubmed PY - 2015/12/15/medline SP - 1 EP - 13 JF - Surgical infections JO - Surg Infect (Larchmt) VL - 16 IS - 1 N2 - BACKGROUND: Necrotizing pancreatitis is a challenging condition that requires surgical treatment commonly and is associated with substantial morbidity and mortality. Over the past decade, new definitions have been developed for standardization of severity of acute and necrotizing pancreatitis, and new management techniques have emerged based on prospective, randomized clinical trials. METHODS: Review of English-language literature. RESULTS: A new international classification of acute pancreatitis has been developed by PANCREA (Pancreatitis Across Nations Clinical Research and Education Alliance) to replace the Atlanta Classification. It is based on the actual local (whether pancreatic necrosis is present or not, whether it is sterile or infected) and systemic determinants (whether organ failure is present or not, whether it is transient or persistent) of severity. Early management requires goal-directed fluid resuscitation (with avoidance of over-resuscitation and abdominal compartment syndrome), assessment of severity of pancreatitis, diagnostic computed tomography (CT) imaging to assess for necrotizing pancreatitis, consideration of endoscopic retrograde cholangiopancreatography (ERCP) for biliary pancreatitis and early enteral nutrition support. Antibiotic prophylaxis is not recommended. Therapeutic antibiotics are required for treatment of documented infected pancreatic necrosis. The initial treatment of infected pancreatic necrosis is percutaneous catheter or endoscopic (transgastric/transduodenal) drainage with a second drain placement as required. Lack of clinical improvement after these initial procedures warrants consideration of minimally invasive techniques for pancreatic necrosectomy including video-assisted retroperitoneal debridement (VARD), minimally invasive retroperitoneal pancreatectomy (MIRP), or transluminal direct endoscopic necrosectomy (DEN). Open necrosectomy is associated with substantial morbidity, but to date no randomized trial has documented superiority of either minimally invasive or open surgical technique. Additional trials are underway to address this. CONCLUSIONS: Severe acute and necrotizing pancreatitis requires a multi-disciplinary treatment strategy that must be individualized for each patient. Optimal treatment of necrotizing pancreatitis now requires a staged, multi-disciplinary, minimally invasive "step-up" approach that includes a team of interventional radiologists, therapeutic endoscopists, and surgeons. SN - 1557-8674 UR - https://www.unboundmedicine.com/medline/citation/25761075/Necrotizing_pancreatitis:_new_definitions_and_a_new_era_in_surgical_management_ L2 - https://www.liebertpub.com/doi/full/10.1089/sur.2014.123?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -