Current management of necrotizing pancreatitis

Abstract

Although necrotizing pancreatitis remains a devastating disease, progress during the past 2 decades has significantly reduced morbidity and mortality. Early recognition of severe disease, using scoring systems or clinical signs, is essential to successful therapy. Standard therapy for patients with severe disease includes early invasive monitoring and resuscitation, prophylactic antibiotics, nutrition, and serial CT scanning and FNA to identify infected necrosis. Recent data suggest that with few exceptions, patients with pancreatic necrosis can be managed with a conservative strategy, reserving surgery or other forms of intervention for documented infection. Such a policy must be flexible, however. Infection may develop late after weeks of sterility, and repeated FNAs are necessary. Conservative management produces a subset of patients with persistent pain, malaise, and an inability to tolerate a diet or return to activities of daily life. These patients with organized necrosis do well with delayed debridement. Although there may still be a subset of patients with sterile necrosis who might benefit from earlier debridement, we have not yet identified a marker for this group.