The American Gastroenterological Association (AGA) has issued a clinical practice update on best practices in the management of pancreatic necrosis.

In this expert review, published in Gastroenterology, the Clinical Practice Updates Committee of the AGA Institute and the AGA Governing Board provide timely guidance on the management of patients with pancreatic necrosis. The review is framed around 15 best practice advice points as well as the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons.

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The update reviews the available evidence, expert recommendations, and concise best practice advice regarding the management of pancreatic necrosis. Management of patients with pancreatic necrosis depends on important issues such as appropriate use of imaging, intravenous fluids, antibiotics, and nutritional support, in addition to the type and timing of endoscopic, radiologic, and/or surgical interventions. Strategies such as antimicrobial therapy, percutaneous drainage, endoscopic necrosectomy, endoscopic step-up therapy, and surgical approaches are also discussed.


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The best practice advice covers broad-spectrum intravenous antibiotics when infected necrosis is suspected, enteral feeding to decrease the risk for infected necrosis, drainage and/or debridement in patients with sterile pancreatic necrosis, percutaneous drainage or transmural endoscopic drainage, as first-line approaches in patients with walled-off pancreatic necrosis (WON), placement of self-expanding metal stents rather than plastic stents for endoscopic transmural drainage of necrosis, and minimally invasive surgeries.

The researchers discussed the necessity of using a multidisciplinary approach, utilizing a specialized referral center with nutritionists, medical intensivists, procedural radiologists, advanced endoscopists, and pancreatic surgeons who have expertise treating this patient population in a multidisciplinary manner. Percutaneous drainage remains an important adjunct or definitive therapy in the early stage of the disease for patients with infection or severe symptoms attributed to pancreatic necrosis.

Recommended strategies for effective interventions in managing patients with this disease include endoscopic ultrasound-guided drainage and direct endoscopic necrosectomy, when required for WON, and a step-up approach that utilizes minimally invasive and open surgical approaches.

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