AGA Issues Best Practices for Pancreatic Necrosis Management

The American Gastroenterological Association (AGA) has released an updated clinical practice guideline that includes 15 best practices for the management of patients with pancreatic necrosis.

The authors, who are advanced endoscopists or hepatopancreatobiliary surgeons, used their own experience, as well as reviewed both landmark and recent manuscripts, to develop the best practices. 

Among the best practices that the authors developed are the following:

• Clinicians should have patients with pancreatic necrosis begin enteral feeding early to minimize the risk of infected necrosis.
• At first, clinicians should avoid pancreatic debridement due to its associated increased morbidity and mortality. Optimally, debridement should be delayed for 4 weeks.
• Clinicians can use percutaneous drainage or transmural endoscopic drainage as a first line, nonsurgical treatment option in walled-off pancreatic necrosis.
• In the endoscopic transmural drainage of necrosis, self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents.
• In the debridement of acute necrotizing pancreatitis, the use of minimally invasive operative approaches is preferred over open surgical necrosectomy due to a lower risk of morbidity. 

In the updated guideline, the authors also highlighted the importance of a multidisciplinary approach.

“Management of patients with pancreatic necrosis is most effective at a specialized referral center with nutritionists, medical intensivists, procedural radiologists, advanced endoscopists, and pancreatic surgeons who have expertise in caring for this complex patient population in a multidisciplinary manner,” the authors wrote.

If a patient with significant pancreatic necrosis does not have local access to a multidisciplinary team, the authors recommended that the patient’s provider consider transferring the patient to a center with the necessary tertiary care.

“While there will always be variations in local expertise and approaches between expert centers, for patients with infection or severe symptoms attributed to pancreatic necrosis, percutaneous drainage remains an important adjunctive or definitive therapy in the early stage of the disease,” the authors wrote.

—Colleen Murphy

Reference:

Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association clinical practice update: management of pancreatic necrosis [published online August 31, 2019]. Gastroenterology. doi:10.1053/j.gastro.2019.07.064.