Acute pancreatitis –  new developments in treatment

Authors: J. Špičák
Authors‘ workplace: Klinika hepatogastroenterologie IKEM Praha, přednosta prof. MU Dr. Julius Špičák, CSc.
Published in: Vnitř Lék 2013; 59(7): 597-605


Acute pancreatitis continues to be a potentially very severe disease. According to new classification schemes, a severe pancreatitis (up to 20%) is conditioned by structural changes and organ failures. The first critical moment concerns a fast development of pancreatic necrosis, followed by delayed infection. The most common complications of pancreatitis include infections, bleeding, compartment syndrome and decompensation of comorbidities. At the early stage the most important measure concerns the active expansion of blood volume and treatment of organ dysfunction. General antibio­tic prophylaxis has been rejected; it is indicated only if there are signs of persistent circular failure and inflammatory response syndrome. The choice of antibio­tic regimens usually includes Ciprofloxacin plus Metronidazole, Imipenem and Propene, administered for at least 10 to 14 days. After that the prophylaxis should be assessed and it may be continued under a changed regimen. The lab tests as well as imaging methods are continuously monitored and the administration of antibio­tics is adequately adjusted. If infection is demonstrated antibio­tics are indicated based on standard microbio­logical parameters and clinical relationships. Any surgical intervention (nephrectomy) is delayed as long as possible. Indication would concern impaired condition despite intensive care, e.g. newly developed sepsis, pains, food intake inability or other complications, such as bleeding. Recently the open surgical nephrectomy is confronted with derivations of infected necrosis via mini‑invasive procedures, such as transcutaneous drainage, laparoscopic video‑ assisted nephrectomy or endoscopic transgastric nephrectomy. The methods may be combined. Mortality and morbidity of mini‑invasive procedures are comparably significantly lower.

Key words:
acute pancreatitis –  acute pancreatitis treatment –  infections –  antibio­tic prophylaxis –  interventions in acute pancreatitis


1. Besselink MG, van Santvoort HC, Boermeester MA et al. Timing and impact of infections in acute pancreatitis. Br J Surg 2009; 96: 267– 273.

2. Bradley EL 3rd. A clinically based classification for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta GA, September 11– 13, 1992. Arch Surg 1993; 128: 586– 590.

3. Zaheer A, Singh VK, Qureshi RO et al. The revised Atlanta classification for acute pancreatitis: updates in imaging terminology and guidelines. Abdom Imaging 2013; 38: 125– 136.

4. Špičák J. Akutní pankreatitida. Praha: Grada 2005.

5. Eckerwall G, Olin H, Andersson B et al. Fluid resuscitation and nutritional support during severe acute pancreatitis in the past: what have we learned and how can we do better? Clin Nutr 2006; 25: 497– 504.

6. Mao EQ, Fei J, Peng YB et al. Rapid hemodilution is associated with increased sepsis and mortality among patients with severe acute pancreatitis. Chin Med J 2010; 123: 1639– 1644.

7. Haydock MD, Mittal A, Wilms HR et al. Fluid therapy in acute pancreatitis: anybody’s guess. Ann Surg 2013; 257: 182– 188.

8. Fisher JM, Gardner TR. The “golden hours” of management in acute pancreatitis. Am J Gastroenterol 2012; 107: 1146– 1150.

9. Büchler MW, Malfertheiner P, Friess H et al. Human pancreatic tissue concentration of bactericidal antibio­tics. Gastroenterology 1992; 103: 1902– 1908.

10. Finch WT, Sawyers JL, Schenker SA. A prospective study to determine the efficacy of antibio­tics in acute pancreatitis. Ann Surg 1976; 183: 667– 672.

11. Pederzoli P, Bassi C, Vesentini S et al. A randomized multicenter clinical trial of antibio­tic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem. Surg Gynecol Obstet 1993; 176: 480– 483.

12. Delcensiere R, Yzet T, Ducroix JP. Prophylactic antibio­tics in treatment of severe acute alcoholic pancreatitis. Pancreas 1996; 13: 198– 201.

13. Sainio A, Kemppainen E, Puolakkainen Pet al. Early antibio­tic treatment in acute necrotising pancreatitis. Lancet 1995; 346: 663– 667.

14. Schwarz M, Isenmann R, Mayer H et al. Antibio­tic use in necrotizing pancreatitis. Results of a controlled study. Dtsch Med Wochenschr 1997; 122: 356– 361.

15. Luiten EJ, Hop WC, Lange JF et al. A control­led clinical trial of selective decontamination for the treatment of severe acute pancreatitis. Ann Surg 1995; 222: 57– 65.

16. Takeda K, Matsumo S, Sunamura M et al. Continuous regional arterial infusion of protease inhibitor and antibio­tics in acute necrotizing pancreatitis. Am J Surg 1996; 171: 394– 398.

17. Mai G, Gloor B, Uhl W et al. Routine antibio­tic prophylaxis in necrotizing pancreatitis in­creased gram‑ positive infectious. Digestion 1999; 60: 360– 389.

18. Bassi C, Falconi M, Talamini G et al. Con­trolled trial of pefloxacin versus imipenem in severe acute pancreatitis. Gastroenterology 1998; 115: 1513– 1517.

19. Manes G, Uomo I, Menchise A et al. Timing of antibio­tic prophylaxis in acute pancreatitis: a controlled randomized study with meropenem. Am J Gastroenterol 2006; 101: 1348– 1353.

20. Isenmann R, Rünzi M, Kron M et al. Prophylactic antibio­tic treatment in patients with predicted severe acute pancreatitis: a placebo‑ controlled, double‑blind trial. Gastroenterology 2004; 126: 997– 1004.

21. Dellinger EP, Tellado JM, Soto NE et al. Early antibio­tic treatment in severe acute necrotizing pancreatitis: a randomized, double‑blind, placebo‑ controlled study. Ann Surg 2007; 245: 674– 683.

22. Røkke O, Harbitz TB, Liljedal J et al. Early treatment of severe pancreatitis with imipenem: a prospective randomized clinical trial. Scand JGastroenterol 2007; 42: 771– 776.

23. Xue P, Deng LH, Zhang ZD et al. Effect of antibio­tic prophylaxis on acute necrotizing pancreatitis: results of a randomized controlled trial. J Gastroenterol Hepatol 2009; 24: 736– 742.

24. García‑Barrasa A, Borobia FG, Pallares R et al. A double‑blind, placebo‑ controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis. J Gastrointest Surg 2009; 13: 768– 774.

25. Spicak J, Hubaczova M, Antos F et al. Antibio­tic prophylaxis of infectious complications in severe acute pancreatitis: Preliminary results of controlled study. Digestion 2000; 61: A287.

26. Golub R, Siddiqi F, Pohl D. Role of antibio­tics in acute pancreatitis: a meta‑analysis. J Gastrointest Surg 1998; 2: 496– 503.

27. Sharma VK, Howden CW. Prophylactic antibio­tic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta‑analysis. Pancreas 2001; 22: 28– 31.

28. Villatoro E, Bassi C, Larvin M. Antibio­tic therapy for prophylaxis against infection of pan­creatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 2006; 4: CD002941.

29. Mazaki T, Ishii Y, Takayama T. Meta‑analysis of prophylactic antibio­tic use in acute necrotizing pancreatitis. Br J Surg 2006; 93: 674– 684.

30. Villatoro E, Mulla M, Larvin M. Antibio­tic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 2010; 5: CD002941.

31. Wittau M, Mayer B, Scheele J et al. Systematic review and meta‑analysis of antibio­tic prophylaxis in severe acute pancreatitis. Scand JGastroenterol 2011; 46: 261– 270.

32. Yao L, Huang X, Li Y et al. Prophylactic antibio­tics reduce pancreatic necrosis in acute necrotizing pancreatitis: a meta‑analysis of randomized trials. Dig Surg 2010; 27: 442– 449.

33. Gloor B, Müller CA, Worni M et al. Pan­creatic infection in severe pancreatitis: the role of fungus and multiresistant organisms. Arch Surg 2001; 136: 592– 596.

34. He YM, Lv XS, Ai ZL et al. Prevention and therapy of fungal infection in severe acute pancreatitis: a prospective clinical study. World J Gastroenterol 2003; 9: 2619– 2621.

35. Eggimann P, Jamdar C, Siriwardena AK. Pro/ con debate: antifugal prophylaxis is important to prevent fungal infection in patients with acute necrotizing pancreatitis receiving broad‑ spectrum antibio­tics. Crit Care 2006; 10: 229– 231.

36. Runzi M, Niebel W, Goebell H et al. Severe acute pancreatitis: nonsurgical treatment of infected necroses. Pancreas 2005; 30: 195– 199.

37. van Brunschot S, Bakker OJ, Besselink MG et al. Treatment of acute pancreatitis. Clin Gastroenterol Hepatol 2012; 10: 520– 524.

38. Besselink MG, van Santvoort HC, Buskens Eet al. Probio­tic prophylaxis in predicted severe acute pancreatitis: a randomised double‑blind, placebo‑ controlled trial. Lancet 2008; 371: 651– 659.

39. Zhang MM, Cheng JQ, Lu YR et al. Use of pre‑, pro‑, a synbio­tics in patients with acute pancreatitis: a meta‑analysis. World J Gastroenterol 2010; 16: 3970– 3978.

40. Besselink MG, de Bruijn MG, Rutten JP et al. Surgical intervention in patients with necrotizing pancreatitis. Br J Surg 2006; 93: 593– 539.

41. Bradley EI 3rd. A fifteen year experience with open drainage for infected pancreatic necrosis. Surg Gynecol Obstet 1993; 177: 215– 222.

42. Bosscha K, Hulstaert PF, Hennipman A et al.Fulminant acute pancreatitis and infected necrosis: results of open management of the abdomen and planned reoperations. J Am Coll Surg 1998; 187: 255– 262.

43. Nieuwenhuijs VB, Besselink MG, van Minnen LP et al. Surgical management of acute necrotizing pancreatitis: a 13‑years experience and a systematic review. Scand J Gastroenterol 2003; 239: 111– 116.

44. Olakowski M, Dranka‑ Bojarowska D, Szlachta‑ Swiatkowska E et al. Management of necrotizing pancreatitis: flexible approach depending on intra‑ operative assessment of necrosis. Acta Chir Belg 2006; 106: 172– 176.

45. Sarr MG, Nagorney DM, Mucha P Jr et al. Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/ debridement and delayed primary wound closure over drains. Br J Surg 1991; 78: 576– 581.

46. Tsiotos GG, Luque‑ de‑ León E, Sarr MG. Long‑term outcome of necrotizing pancreatitis treated by necrosectomy. Br J Surg 1998; 85: 1650– 1653.

47. Howard TJ, Patel JB, Zyromski N et al. Declining morbidity and mortality rates in the surgical management of pancreatic necrosis. J Gastrointest Surg 2077; 11: 43– 49.

48. Fernandez‑ del Castillo C, Rattner DW, Makary MA et al. Debridement and closed packing for the treatment of necrotizing pancreatitis. Ann Surg 1998; 228: 676– 684.

49. Rodriguez JR, Razo AO, Targarona J et al. Debridement and closing packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 2008; 247: 294– 299.

50. Beger HG, Büchler M, Bittner R et al. Necrosectomy and postoperative local lavage in patients with necrotizing pancreatitis: results of a prospective clinical trial. World J Surg 1988; 12: 255– 262.

51. Büchler MW, Gloor B, Müller CA et al. Acute necrotizing pancreatitis: treatment strategy according to status of the infection. Ann Surg 2000; 232: 619– 626.

52. Rau B, Bothe A, Beger HG. Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19‑year, single‑center series. Surgery 2005; 138: 28– 39.

53. Reddy M, Jindal R, Gupta R et al. Outcome after pancreatic necrosectomy: trends over 12 years at an Indian centre. ANZ J Surg 2006; 76: 704– 709.

54. Farkas G, Marton J, Mandi Y et al. Surgical management and complex treatment of infected pancreatic necrosis: 18‑year experience at a single center. J Gastroenterol Surg 2006; 10: 278– 285.

55. van Santvoort HC, Besselink MG, Bakker OJet al. A step‑ up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362: 1491– 1502.

56. Büchler MW, Gloor B, Müller CA et al. Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 2000; 232: 619– 626.

57. Rau B, Bothe A, Beger HG et al. Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristic and outcome in 19‑year, single center series. Surgery 2005; 138: 28– 39.

58. Howard TJ, Patel JB, Zyromski N et al. De­clining morbidity and mortality rates in the surgical management of pancreatic necrosis. J Gastro­intest Surg 2007; 11: 43– 49.

59. Alsfasser G, Schwandner F, Pertschy A et al.Treatment of necrotizing pancreatitis: redefining the role of surgery. World J Surg 2012; 36: 1142– 1147.

60. Freeny PC, Hauptmann F, Althaus SJ et al. Percutaneous CT‑ guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results. AJR Am J Roedntgenol 1998; 170: 969– 975.

61. van Santwoort HC, Besselink MG, Bakker OJet al. A step‑ up approach or open necrosectomy for necrotiozing pancreatitis. N Engl J Med 2010; 362: 1491– 1502.

62. Mortelé KJ, Girshman J, Szejnfeld D et al. CT‑ guided percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J Roentgenol 2009; 192: 110– 116.

63. Bruennler T, Langgartner J, Lang S et al. Outcome of patients with acute, necrotizing pancreatitis requiring drainage‑ does drainage size matter? World J Gastroenterol 2008; 14: 725– 730.

64. Lee JK, Kwak KK, Park JK et al. The efficacy of nonsurgical treatment of infected pancreatic necrosis. Pancreas 2007; 34: 399– 404.

65. Baril NB, Ralls PW, Wren SM et al. Does an infected peripancreatic fluid collection or ab­scess mandate operation? Ann Surg 2000; 231: 361– 367.

66. Gambiez LP, Denimal FA, Porte HL et al. Retroperitoneal approach and endoscopic ma­nagement of peripancreatic necrosis collections. Arch Surg 1998; 133: 66– 72.

67. Seifert H, Biermer M, Schmitt W et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long‑term follow‑up (the GEPARD study). Gut 2009; 58: 1260– 1266.

68. Coelho D, Ardengh JC, Eulálio JM et al. Management of infected and sterile pancreatic necrosis by programmed endoscopic necrosectomy. Dig Dis 2008; 26: 364– 369.

69. Escourrou J, Shehab H, Buscail L et al. Peroral transgastric/ transduodenal necrosectomy: access in the treatment of infected pancreatic necrosis. Ann Surg 2008; 248: 1074– 1080.

70. Lopes CV, Pesenti C, Bories E et al. Endoscopic‑ ultrasound‑ guided endoscopic transmural drainage of pancreatic pseudocysts and absces­ses. Scand J Gastroenterol 2007; 42: 524– 529.

71. Voermans RP, Veldkamp MC, Rauws EA et al. Endoscopic transmural debridement of symptomatic organized pancreatic necrosis (with videos). Gastrointest Endosc 2007; 66: 909– 916.

72. Papachristou GI, Takahashi N, Chahal P et al. Peroral endoscopic drainage/ debridement of walled‑off pancreatic necrosis. Ann Surg 2007; 245: 943– 951.

73. Hookey LC, Debroux S, Delhaye M et al. Endoscopic drainage of pancreatic‑ fluid collection in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc 2006; 63: 635– 643.

74. Baron TH, Harewood GC, Morgan DE et al. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002; 56: 7– 17.

75. Parekh D. Laparoscopic‑ assisted pan­creatic necrosectomy: a new surgical option for treatment of severe necrotizing pancreatitis. Arch Surg 2006; 141: 895– 902.

76. Zhu JF, Fan XH, Zhang XH. Laparoscopic treatment of severe acute pancreatitis. Surg Endosc 2001; 15: 146– 148.

77. Raraty MG, Halloran CM, Dodd S et al. Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 2010; 251: 787– 793.

78. Chang YC, Tsai HM, Lin XZ et al. No debridement is necessary for symptomatic or infected acute necrotizing pancreatitis: delayed, mini‑retroperitoneal drainage for acute necrotizing pancreatitis without debridement and irrigation. Dig Dis Sci 2006; 51: 1388– 1395.

79. Castellanos G, Piñero A, Serrano A et al. Translumbar retroperitoneal endoscopy: an alternative in the follow‑up and management of drained infected pancreatic necrosis. Arch Surg 2005; 140: 952– 955.

80. Carter CR, McKay CJ, Imrie CW. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann Surg 2000; 232: 175– 180.

81. Seifert H, Biermer M, Schmitt W et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicenter study with long‑term follow‑up (the GEPARD Study). Gut 2009; 58: 1260– 1266.

82. van Santwoort HC, Besselink MG, Bakker OJet al. A step‑ up approach or open necrosectomy for necrotiozing pancreatitis. N Engl J Med 2010; 362: 1491– 1502.

83. Bakker OJ, van Santvoort HC, van Brunschot Set al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012; 307: 1053– 1061.

84. Horvath K, Freeny P, Escallon J et al. Safety and efficacy of video‑ assisted retroperitoneal debridement for infected pancreatic col­lections: a multicenter, prospective single‑arm phase 2 study. Arch Surg 2010: 145: 817– 825.

Diabetology Endocrinology Internal medicine
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account