Management of Infected Necrosis: Step-Up Approach

When infected necrosis is clinically or radiologically suspected in a patient with necrotizing pancreatitis, antibiotic therapy is indicated. An intervention is indicated in patients who fail to improve or who show clinical deterioration under antibiotic therapy. Because of the higher number of interventions in patients who undergo immediate drainage, invasive intervention should preferably be delayed until collections have become walled-off. This process typically takes 3 to 4 weeks after the onset of disease. Radiologically guided percutaneous catheter or endoscopic transluminal drainage is the first step in the step-up approach. The choice of one approach over another is based on multiple factors including characteristics of the collection. Since, the rate of pancreatic fistulas is lower in patients who undergo endoscopic drainage, this should be the preferred method when possible. More than half of the patients will require additional necrosectomy following endoscopic drainage and about half will require minimally invasive surgical necrosectomy following percutaneous catheter drainage. There are no differences in outcomes such as major complications and death when comparing endoscopic with a surgical step-up approach. There are various newer and more conventional devices for endoscopic necrosectomy. There are also different techniques for surgical necrosectomy, varying from open to various minimally invasive approaches described, including percutaneous necrosectomy, video-assisted retroperitoneal debridement, laparoscopic transgastric necrosectomy, laparoscopic cystgastrostomy, and personal variations on the aforementioned techniques. Some patients may require multimodal interventions. Decisions should be tailormade by a specialized multidisciplinary team.