A 58-Year-Old Man in Severe Abdominal Pain
Correct Answer: A
The presenting patient has experienced a bout of severe acute necrotizing pancreatitis and now has suffered a serious complication in which necrotizing pancreatitis can potentially lead to infection. This will be the second What’s The Take Home involving acute necrotizing pancreatitis. The initial phases of therapy seem settled. Instead of early debridement surgery, fluid removal procedures, and prophylactic antibiotics, early enteral feeding, and conservative waiting for the “walling off” process, generally accepted as 4 weeks prior to any invasive intervention, is now the appropriate treatment approach.1-4 But there remains one dangerous situation to consider: infection. For pancreatic infection, immediate drainage either via open surgical, transcutaneous catheter, or endoscopic catheter techniques have been the standard of care.5 However, accruing data now exists to change this paradigm.
In a randomized, multi-center trial, Boxhorn and colleagues1 randomized 104 well-matched patients with acute necrotizing pancreatitis that had devolved into infection. Half of the patients in the study had immediate (within 24 hours) surgery while the other half received antibiotics and supportive care alone until either full resolution/recovery, clinical deterioration defined as organ failure or sepsis syndrome, or 28 days duration in the absence of clinical improvement had transpired. The latter two categories then received either urgent (in the deterioration group) or planned drainage in the 28 days without resolution. The authors found that there was no difference in the primary endpoint between the two groups. Additionally, at 6 months, there was no statistical difference in mortality between the two groups. A 6-month evaluation for delayed exocrine and endocrine pancreatic function also was equivalent in both groups.6
Some subtle and interesting differences were evident despite the equivalence of the three primary endpoints discussed above. The study was designed as a noninferiority trial, so the following data were not predefined endpoints. However, as a group the conservatively treated patients underwent less procedures (2.6 vs 4.4), were hospitalized 8 less days (51 vs 59), and most strikingly, necrotizing pancreatitis resolved without the need for a procedure at all in 19 patients in the conservatively treated group.
From this data, I conclude that waiting is noninferior and perhaps even the superior approach. In his editorial on this topic, Dr Todd Baron, another well-published, long-time expert on acute pancreatitis3, comes to a similar conclusion. He noted that “perhaps delaying drainage of infected necrosis (be it surgical, percutaneous or endoscopic) resulting in worse outcomes” is simply not true3 and that the total “management of acute necrotizing pancreatitis is now predominantly non-surgical” even when infection ensues when delay of ≥ 30 days for the walling off process has taken place.3,7
Answer A is a direct statement in agreement with the above data and discussion and is the correct choice here. Answer B and C differentiate between two catheter drainage strategies which are effective, but both the timelines presented are no longer required. Answer D is even more aggressive both in time and procedures.
Patient Follow Up
The clinical signs of sustained fever and leukocytosis fulfilled clinical criteria to assume the presence of infected necrotizing pancreatitis. This was further confirmed by the presence of a positive gram stain on fine-needle aspiration. We initiated antibiotics capable of pancreatic penetration: piperacillin, tazobactam, and metronidazole. After much consultation and discussion, since the patient was stable other than fever, conservative management without procedure in the intensive care unit was initialed. Within 48 hours the fever and WBC lowered. He became afebrile after 5 days. A repeat imaging study was unchanged. After another week, he was afebrile with WBC within normal limits and minimal pain. At week 3, an imaging study indicated improvement with significant “walling off” of necrotic areas and fluid collections. The plan was to continue conservative management, with a contingency that we proceed to catheter drainage in the event of marked clinical deterioration like an organ failure, new fevers, or WBC elevations. None of these occurred, and the patient was discharged on day 50. He was asymptomatic and clinically well at his 1-week and 4-week follow-up visits.
What’s The Take Home?
Acute necrotizing pancreatitis, once a common etiology for abdominal surgeries in the form of various debridement and drainage procedures, is now evolving into a more conservatively and medically treated entity. The diagnosis and management of acute (necrotizing or not) pancreatitis was reviewed in a What’s The Take Home in 2021.1 Since then, a new study has demonstrated that even in patients with infection, a stepwise conservative approach is at least equivalent to immediate surgery when looking at mortality and post-recovery pancreatic function at 6 months.6
The evolving paradigm for patients presenting with acute necrotizing pancreatitis is to not perform surgical necrosectomy to defer prophylactic antibiotics, and to feed as early as tolerated with enteral feeding. Subsequently, if the clinical status remains stable, approximately 4 weeks should elapse to allow “walled off necrosis” to occur before any endoscopic, percutaneous, or surgical procedure is considered. Further, even if signs of infection occur, such as sustained fevers, leukocytosis, elevated inflammatory markers, or gas patterns on imaging, a trial of delayed drainage, conservative supportive therapy, and antibiotics can result in noninferior mortality statistics, equivalent long-term pancreatic function, and decreased number of interventions.6 Indeed, it seems that sometimes less is more.
- Boxhorn L, van Dijk SM, van Grinsven J, Verdonk RC, et al. Immediate versus postponed intervention for infected necrotizing pancreatitis. N Eng J Med. 2021;385:1372-1381. doi:10.1056/NEJMoa2100826
- Besselink MG, Vermer TJ, Schoenmaekers EJ, et al. Timing of surgical intervention in necrotizing pancreatitis. Arch Surg. 2007;142:1184-2001. doi:10.1001/archsurg.142.12.1194
- Mier J, Leon EL, Castillo A, Robledo F, Blanco R. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg. 1997;173:71-75.doi:10.1016/S0002-9610(96)00425-4
- Van Brunscot S, van Grinsven J, van Santvoort HC, et al. Endoscopic or surgical step up approach for infected necrotizing pancreatitis: A multicenter randomized trial. Lancet. 2018;391:51-58. doi:10.1016/S0140-6736(17)32404-2
- Van Santvoort HC, Besselink MG, Bakker OJ, et al. A step up approach or open necrostomy for necrotizing pancreatitis. N Eng J Med. 2010; 362: 1491-1502. doi:10.1056/NEJMoa0908821
- Bradley EL III, Dexter ND. Management of severe acute pancreatitis: A surgical odyssey. Ann Surg. 2010;25:6-17. doi:10.1097/SLA.0b013e3181c72b79
- Barron TH. Drainage for infected pancreatic necrosis – Is the waiting the hardest part? N Eng J Med. 2021;385:1433-1435. doi:10.1056/NEJMe2110313