Consider Transferring Pancreatic-Necrosis Patients if Clinical Expertise is Limited: Recommendations

By Will Boggs MD

September 17, 2019

NEW YORK (Reuters Health) - A clinical-practice update from the American Gastroenterological Association provides 15 "best practices" for the management of pancreatic necrosis.

"Pancreatic necrosis is associated with substantial morbidity and mortality, and optimal management requires a multidisciplinary approach," Dr. Andrew Y. Wang from University of Virginia, in Charlottesville, and colleagues write in Gastroenterology, online August 31.

"In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center," they add in "Best Practice Advice 1."

For their report, the authors reviewed the available evidence and expert recommendations on the clinical care of patients with pancreatic necrosis.

While routine use of prophylactic antibiotics is not recommended, they say, broad-spectrum intravenous antibiotics that are able to penetrate pancreatic necrosis should be favored for culture-proven infection and pancreatic necrosis or when infection is strongly suspected.

Enteral feeding should be initiated early to decrease the risk of infected necrosis, whereas total parenteral nutrition should be considered only where oral or enteral feeds are not feasible or tolerated, the authors say.

"Even in patients with necrotizing pancreatitis - in particular, those who are not in extremis (e.g., not intubated in the ICU with an ileus, etc.) - an early trial of oral nutrition (eating by mouth) is reasonable," Dr. Wang told Reuters Health by email. "However, if patients do not tolerate oral feeding over a finite period of observation (such as 1-2 days), enteric feeding should be rapidly initiated."

Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis, but debridement should be delayed for four weeks and only performed earlier when there is an organized collection and a strong indication, according to the recommendations.

Direct endoscopic necrosectomy (DEN) should be reserved for patients with limited necrosis who did not adequately respond to endoscopic transmural drainage.

The clinical-practice update recommends a step-up approach consisting of percutaneous drainage or endoscopic transmural drainage, followed by DEN, and then surgical debridement, as indicated for a particular patient.

"Lumen-apposing metal stents (LAMS) have made endoscopically accessing areas of walled-off pancreatic necrosis (WON) relatively easy and safe, and in some cases placement of a LAMS without direct endoscopic necrosectomy may be all that is required to treat patient with limited infected or symptomatic WON," Dr. Wang said.

"In a subset of patients with more mature and accessible infected WON, endoscopic necrosectomy can reduce downstream morbidity and in many cases it may be a life-saving intervention," he said. "However, endoscopic necrosectomy can result in severe bleeding and/or unintended perforations. As such, these procedures really should be performed by experienced endoscopists at a referral center that possesses experienced interventional radiology and surgical backup and also can offer the multidisciplinary care required to optimally manage these very sick patients."

The update also addresses percutaneous and transmural endoscopic drainage, the use of stents, a preference of minimally-invasive operative approaches over open surgical necrosectomy, and the need for definitive surgical management with distal pancreatectomy for some patients.

SOURCE: https://bit.ly/2kazjg7

Gastroenterology 2019.

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