Approach to the Diagnosis and Management of Infected Pancreatic Necrosis: A Narrative Review

TL;DR

This paper reviews the diagnosis and treatment of infected pancreatic necrosis, emphasizing early detection and minimally invasive approaches to improve patient outcomes.

Contribution

The paper provides a comprehensive narrative review of current strategies for managing infected pancreatic necrosis, highlighting the step-up approach and multidisciplinary care.

Findings

Contrast-enhanced CT is the preferred imaging modality for diagnosing infected pancreatic necrosis.

Minimally invasive procedures, including percutaneous drainage and endoscopic interventions, are central to treatment and improve outcomes.

A multidisciplinary team approach is essential for maximizing patient outcomes in infected pancreatic necrosis.

Abstract

Infected pancreatic necrosis (IPN) is a dreaded complication of acute necrotizing pancreatitis and is linked to persistent organ failure, sepsis, and increased morbidity and mortality. Clinical indicators of IPN include fever, clinical deterioration, and worsening inflammatory markers. The diagnosis of IPN is based on clinical signs, microbiological confirmation, and radiological evidence, with contrast-enhanced CT being the preferred imaging modality. In the absence of tests with high sensitivity, a high clinical suspicion is required for early recognition and treatment. Although there is no way to prevent IPN, a systematic management approach with parenteral antibiotics, nutritional management, and minimally invasive procedures has become the cornerstone of the treatment. The step-up approach includes minimally invasive procedures that minimize procedure-related complications and are associated with improved outcomes. The percutaneous route remains the most common route for drainage, while endoscopic interventions are preferred for perigastric or periduodenal encapsulated collections. The use of lumen-apposing metal stents is associated with excellent outcomes in cases of infected walled-off necrosis. Patients with significant quantities of infected necrosis may benefit from direct or percutaneous endoscopic necrosectomy. Minimally invasive surgical techniques followed by open surgeries are reserved for patients who do not improve with percutaneous or endoscopic necrosectomies. The outcome can be maximized through a multidisciplinary approach by a team of interventional radiologists, advanced therapeutic endoscopists, and surgeons.

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