This document discusses the treatment of a patient with necrotizing pancreatitis. It describes imaging that showed a pancreatic duct disruption and placement of pancreatic and paracolic drains. Surgical options of further ERCP, pancreatic stenting, or necrosectomy are considered. Early necrosectomy is not recommended due to risks of incomplete debridement and higher morbidity. Optimal timing is 4 weeks after onset when inflammation decreases and tissue organization occurs, allowing distinction of live from dead tissue. Endoscopic debridement is an option for selected patients with walled-off necrosis.

1. Necrotizing pancreatitis
Dr Carunya Mannan

2. CT Abdomen
25/03/2015

3. CT Abdomen
30/03/2014 – 5 days after pigtail catheter placement

4. ERCP

5. CT Abdomen
06/04/15 – 12 days after placement of pigtail catheter, 6 days after
pancreatic stent placement

6. Drains
 Paracolic drain – Intially 5 days – about 100ml/day
 Next 10-12 days – Reduced to 5-10ml/ day
 Following that, increased again to 25-75ml/day
 Significant peritubal leak
 17/4/15 – paracolic drain was accidentally dislodged
 Pancreatic drain – no significant output, was
removed.
 Nasopancreatic drain – placed at ERCP

7. Present clinical status
 Poor nutritional status
 Persistent electrolyte imbalance


8. What Next?

9. ERCP?
 Will a longer pancreatic stent help? To seal the duct
disruption?

10. Pancreatic & biliary stents, Gastrointestinal Endoscopy, Volume 77, No. 3 : 2013

11. Surgery?
 Pancreatic necrosis -- > secondary infection
(bacterial/fungal) or symptomatic sterile necrosis
 Chronic low grade fever, nausea, lethargy, anorexia
 Excise all dead/devitalized pancreatic and
peripancreatic tissue
 Preserve viable functioning pancreas, control
resultant pancreatic fistulas, to limit extraneous
organ damage

12. When to debride?

13. Timing Of Debridement
 Early organ failure attributable to systemic inflammatory response syndrome /cytokines
 Late organ failure predominately attributable to infection in necrosis and sepsis
 Delayed debridement - clinical stabilization of the patient, resolution of early organ
failure, decrease in the intense inflammatory reaction in the retroperitoneum

14. Why not early debridement?
 Intra-abdominal hypervascularity
 Altered anatomic relationships
 Inability to discriminate dead from surrounding live
tissue
 Incomplete removal of necrotic tissue and a high rate
of injury to normal surrounding tissues
 Higher morbidity and mortality rate and frequently
require multiple surgical procedures for persistent
pancreatic necrosis/repair of iatrogenic damage
Mier J, León EL, Castillo A, et al. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg 1997; 173:71.
Hartwig W, Maksan SM, Foitzik T, et al. Reduction in mortality with delayed surgical therapy of severe pancreatitis. J Gastrointest
Surg 2002; 6:481.

15. Timing Of Debridement
 Optimal time for surgical debridement - four weeks
after the onset of pancreatitis
 Vascular inflammation - decreased
 Organization of the process
 Delineation of live from dead tissue
 Definitive operative debridement
Wysocki AP. Walled-off pancreatic necrosis: wishing our pancreatitis nomenclature was correct. World J Gastroenterol 2010;
16:4497.

16. Endoscopic debridement
 Transgastric / transduodenal approach
 Limited to patients with walled-off pancreatic necrosis
 Targeted approach to focal pancreatic necrosis with a
reduction in the SIRS/ avoidance of the wound
complications that are associated with major laparotomy
incisions
 Meta-analysis of endoscopic drainage – 69% success
rate, 34% morbidity rate, 2% mortality rate
 One-third of patients initially treated with endoscopic
debridement – needed open surgical debridement
van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;
362:1491.
Bradley EL 3rd, Howard TJ, van Sonnenberg E, Fotoohi M. Intervention in necrotizing pancreatitis: an evidence-based review of surgical and
percutaneous alternatives. J Gastrointest Surg 2008; 12:634

17. Pancreatic necrosectomy

18. Intraop
Pancreatic stent

19. Pancreatic necrosectomy

20. Pancreatic necrosectomy

21. Pancreatic necrosectomy