Interventions for Necrotizing Pancreatitis
Interventions for Necrotizing Pancreatitis
The primary indication for intervention in necrotizing pancreatitis is presence of infected necrosis. Sterile acute necrotic collections almost never warrant intervention early in the course of the disease, that is, in the first 4 weeks. Interventions should be considered later in course of sterile necrotizing pancreatitis only in the presence of disabling symptoms such as persistent pain requiring narcotics, in the presence of gastric outlet or biliary obstruction inability to eat and/or failure to thrive (continued systemic illness, anorexia and weight loss). Currently there is a clear consensus that to optimize outcomes, interventions should be delayed until there is 'walled off' necrosis (WON), which can involve the pancreas itself, peri-pancreatic tissues, or both. WON (formerly known as organized necrosis) represents a well-demarcated collection of necrotic debris that replaces portions of the pancreas and/or peri-pancreatic tissues, especially the retroperitoneal fat. Walled-off necrosis typically evolves four or more weeks after onset of AP. Larger size, extension into retroperitoneum, irregular wall definition and the presence of fat attenuation and debris enables CECT to distinguish WON from pseudocysts. Asymptomatic WON does not mandate intervention regardless of the size and extension of the collection, and may resolve spontaneously over time. However, WON may become infected, obstruct or fistulize to adjacent anatomical structures, or can compress or erode into vasculature causing major hemorrhage, and can thus markedly impact the clinical course of patients with severe acute pancreatitis. Interventions for pancreatic or peri-pancreatic necrosis within the first few weeks are generally associated with adverse outcomes and are typically reserved for infected necrosis in severely deteriorating patient. The primary exception is in the setting of abdominal compartment syndrome, wherein surgical or image-guided decompression is potentially lifesaving, but involves primarily fasciotomy and does not include debridement or drainage of acute necrotic collections. Currently the consensus is that interventions for walled-off necrosis should be delayed as long as possible, preferably to at least 3–4 weeks after onset of disease, to allow liquefaction and encapsulation of necrotic collection.
Indications and Timing for Intervention
The primary indication for intervention in necrotizing pancreatitis is presence of infected necrosis. Sterile acute necrotic collections almost never warrant intervention early in the course of the disease, that is, in the first 4 weeks. Interventions should be considered later in course of sterile necrotizing pancreatitis only in the presence of disabling symptoms such as persistent pain requiring narcotics, in the presence of gastric outlet or biliary obstruction inability to eat and/or failure to thrive (continued systemic illness, anorexia and weight loss). Currently there is a clear consensus that to optimize outcomes, interventions should be delayed until there is 'walled off' necrosis (WON), which can involve the pancreas itself, peri-pancreatic tissues, or both. WON (formerly known as organized necrosis) represents a well-demarcated collection of necrotic debris that replaces portions of the pancreas and/or peri-pancreatic tissues, especially the retroperitoneal fat. Walled-off necrosis typically evolves four or more weeks after onset of AP. Larger size, extension into retroperitoneum, irregular wall definition and the presence of fat attenuation and debris enables CECT to distinguish WON from pseudocysts. Asymptomatic WON does not mandate intervention regardless of the size and extension of the collection, and may resolve spontaneously over time. However, WON may become infected, obstruct or fistulize to adjacent anatomical structures, or can compress or erode into vasculature causing major hemorrhage, and can thus markedly impact the clinical course of patients with severe acute pancreatitis. Interventions for pancreatic or peri-pancreatic necrosis within the first few weeks are generally associated with adverse outcomes and are typically reserved for infected necrosis in severely deteriorating patient. The primary exception is in the setting of abdominal compartment syndrome, wherein surgical or image-guided decompression is potentially lifesaving, but involves primarily fasciotomy and does not include debridement or drainage of acute necrotic collections. Currently the consensus is that interventions for walled-off necrosis should be delayed as long as possible, preferably to at least 3–4 weeks after onset of disease, to allow liquefaction and encapsulation of necrotic collection.
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