Early (<4 Weeks) Versus Standard (≥ 4 Weeks) Endoscopically Centered Step-Up Interventions for Necrotizing Pancreatitis

American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis

“…While data have emerged that endoscopic step-up therapy and DEN starting at <4 weeks are clinically possible when indicated, patients who could clinically wait 4 weeks before endoscopic intervention had decreased mortality. 25 The duration of stent placement is variable. Plastic stents can remain in place until the collection resolves, as evidenced by cross-sectional imaging studies, and potentially indefinitely for prevention of disconnected duct syndrome when the main pancreatic duct has been disrupted.…”

Infected Necrotizing Pancreatitis: Evolving Interventional Strategies From Minimally Invasive Surgery to Endoscopic Therapy—Evidence Mounts, But One Size Does Not Fit All

“…22 In 1 center with a 10-year history of aggressive endoscopically centered minimally invasive multimodal intervention for necrotizing pancreatitis, applied to nearly 300 patients, fully 7% of patients undergoing early intervention at <4 weeks required open surgery for salvage of refractory necrosis, or complications such as bowel perforation. 20 What approach should we recommend for patients with infected necrosis? In those who are stable, but intervention is required because of clinical deterioration, either endoscopic drainage or a step-up approach with percutaneous drainage followed by VARD should be undertaken, depending on local expertise and the location of the collection.…”

“…However, a recent study has shown that early endoscopically centered intervention (<4 weeks) in the face of clinical deterioration with organ failure provided acceptable results without any difference in complications, compared with standard intervention after 4 weeks. 20 Of the 193 patients who required intervention in that study, 76 underwent early and 117 standard intervention. As compared with standard intervention, early intervention was more often performed for infected necrosis with deteriorating organ failure, which improved dramatically after intervention in both groups.…”

Percutaneous Endoscopic Necrosectomy (PEN): Is the PEN Mightier Than the VARD?

“…Very often, necrotic collections get infected which warrants drainage and debridement. Infected necrosis, typically a late event in the natural course of AP, can occur early in a quarter of the patients [2]. Typically, this is managed conservatively with intravenous antibiotics as current guidelines recommend delaying invasive intervention for at least 4 weeks after initial presentation to allow the collection to become "walled off" [3].…”

“…Typically, this is managed conservatively with intravenous antibiotics as current guidelines recommend delaying invasive intervention for at least 4 weeks after initial presentation to allow the collection to become "walled off" [3]. Occasionally necrotizing pancreatitis with clear evidence of infection despite maximal medical support may warrant an earlier intervention for drainage and/or debridement [2].…”