Acute Pancreatitis: Timing of Interventions for Complications

Acute pancreatitis is the leading cause of hospitalization related to digestive illness. While there remains a lack of effective pharmacologic therapy for this disease, there has nevertheless been tremendous progress in management. Many of these developments are centered on the concept of minimally invasive approaches to care. There are several key concepts in the contemporary management of acute pancreatitis. These include both the selection and timing of interventions. For years, aggressive fluid resuscitation has been the mainstay of early treatment. However, there is a lack of data regarding optimal approaches to fluid resuscitation. How then should we proceed in the absence of evidence for any particular resuscitation strategy? An individualized approach seems most likely to ensure the best outcomes for our patients. This involves a volume challenge with intravenous bolus followed by adjustments based on a patients initial response.

The ongoing assessment of a patients clinical status is also critical. While several systems exist to help classify patients in terms of severity, real-time assessment is still guided by clinical parameters. The systemic inflammatory response syndrome can assess for active inflammation, which is often an indicator of ongoing disease activity. Alternatively, the resolution of pain and return of appetite are encouraging signs of recovery in patients with acute pancreatitis.

A subset of patients will progress to severe necrotizing pancreatitis. These are the patients who are most likely to benefit from the latest developments in treatment. First, it is important to recognize that the presence of necrosis alone is not an indication for intervention. However, what if we are faced with a patient who is early in his or her disease course and has persistent systemic inflammatory response syndrome or signs of organ failure in the setting of pancreatic necrosis? Infected pancreatic necrosis within the first week of disease onset is exceedingly rare. At this stage of illness, the emphasis would be appropriately placed on the provision of maximal supportive care that includes enteral nutritional support. In terms of timing, the evidence supports an on- demand approach such that enteral nutrition is started once it becomes clear that a patient is unlikely to resume oral intake within the next few days, for example in the setting of protracted pain, acute respiratory failure or hemodynamic instability.

Ultimately, a multi-disciplinary, team-based approach that leverages local expertise is needed to provide optimal care for these highly complicated cases of acute pancreatitis.

Another critical aspect in the management of necrotizing pancreatitis is the timing of intervention. During the first several weeks of acute pancreatitis, acute fluid collections are poorly organized and drainage procedures are unlikely to be effective at this stage. Therefore, delayed intervention is the current mainstay of treatment. How long should that delay be? Four weeks is often used as an estimate for appropriate timing for a drainage procedure. However, the primary consideration should be the adequate maturation of peri-pancreatic collection(s). A repeat cross-sectional imaging study performed prior to a planned intervention will provide critical information regarding the location and stability of a collection. Percutaneous, using a laparoscope, and endoscopic debridement have emerged as the two primary approaches to drainage of necrotic collections. At our institution, as in many other tertiary facilities, both approaches are available. We favor percutaneous debridement in patients with hemodynamic instability who are unable to tolerate an endoscopic procedure. A key aspect of successful percutaneous debridement is the regular irrigation of the catheter. If necessary, upsizing the catheter can be helpful as well, and in select cases, can provide definitive management for these collections. Alternatively, endoscopic approaches can be very effective in managing collections located directly behind the stomach or duodenum. Given the difficulty of determining the extent of necrotic material within a collection based on imaging alone, the endoscopist should be prepared to perform a direct endoscopic necrosectomy if necessary. Ultimately, a multi-disciplinary, team-based approach that leverages local expertise is needed to provide optimal care for these highly complicated cases of acute pancreatitis.

Finally, it is important to also note recent progress in the prevention of acute pancreatitis. In addition to prophylactic pancreatic duct placement, the use of rectal indomethacin is now widely accepted as an important measure for prevention of post- ERCP pancreatitis in high-risk patients. There is now level-one evidence supporting the efficacy of repeated alcohol cessation counseling in the case of alcohol-related acute pancreatitis and early cholecystectomy in the setting of biliary pancreatitis in the reduction of recurrent acute pancreatitis incidents.

In summary, there have been many exciting developments in the management and prevention of acute pancreatitis. Successful implementation of these approaches holds the promise of greatly improving outcomes for our patients.

Dr. Wu has no conflicts to disclose.

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