Clinical Challenges in Hepatobiliary Surgery: Necrotizing Pancreatitis, Time to Step Up!

Jul 7, 2025

Explore the complexities of necrotizing pancreatitis in critically ill patients. The discussion highlights a step-up approach for intervention, emphasizing timely physiologic optimization and the importance of collaboration in care. Listeners learn about the nuances of various treatment options, including endoscopic and surgical techniques. Insights into managing complications, nutritional support, and the timing of gallbladder removal provide a comprehensive overview of this challenging condition. Patience and proactive care are key to patient recovery.

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INSIGHT

Triage By Cause, Physiology, Imaging

Clarify etiology, physiologic status, and high-quality axial imaging when evaluating necrotizing pancreatitis.
These three factors triage patients into ICU care versus watchful optimization and nutrition support.

ADVICE

Don't Rush Surgery In Early Multi‑Organ Failure

Avoid early operative intervention in multi-organ failure; let physiologic reserve recover when possible.
Treat elevated bladder pressures cautiously and prioritize supportive care over decompressive laparotomy unless clear abdominal compartment syndrome exists.

INSIGHT

Step‑Up Strategy Changed Practice

The PANTR trial showed percutaneous drainage often controls infected necrosis and avoids immediate open necrosectomy.
Up to ~35% of patients resolved with drainage alone, changing standard practice to a step-up algorithm.

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In the corner of the ICU, on multiple pressors, distended, oliguric, and intubated you’ll find the necrotizing pancreatitis patient. Sounds intimidating, but with the persistence, patience, and the proper care these patients can make it! In this episode from the HPB team at Behind the Knife listen in as we discuss the Step-Up approach, when to surgically intervene, various approaches to pancreatic Necrosectomy, and additional aspects of the multidisciplinary care required for the successful treatment of necrotizing pancreatitis.

Hosts
Anish J. Jain MD (@anishjayjain) is a current PGY3 General Surgery Resident at Stanford University and a former T32 Research Fellow at the University of Texas MD Anderson Cancer Center.

Jon M. Harrison is a 2nd year HPB Surgery Fellow at Stanford University. He will be joining as faculty at the Massachusetts General Hospital in Boston, MA at the conclusion of his fellowship in July 2024.

Learning Objectives
· Develop an understanding of the severity of necrotizing pancreatitis and the proper indications to surgical intervene on this often-tenuous patients.
· Develop an understanding of the Step-Up approach and key aspects (reimaging, clinical status, physiologic status, etc.) that determine when to “step-up” treatment for patients with necrotizing pancreatitis.
· Develop an understanding of long term sequalae and complications associated with necrotizing pancreatitis and operative management
· Develop an understanding of multidisciplinary care and long-term follow-up necessary for adequate treatment of patients suffering from necrotizing pancreatitis.

Suggested Reading

Maurer LR, Fagenholz PJ. Contemporary Surgical Management of Pancreatic Necrosis. JAMA Surg. 2023;158(1):81–88. doi:10.1001/jamasurg.2022.5695 https://pubmed.ncbi.nlm.nih.gov/36383374/

Harrison JM, Day H, Arnow K, Ngongoni RF, Joseph A, Aldridge T, Wheeler KJ, DeLong JC, Bergquist JR, Worth PJ, Dua MM, Friedland S, Park W, Eldika S, Hwang JH, Visser BC. What's Behind it all: A Retrospective Cohort Study of Retrogastric Pancreatic Necrosis Management. Ann Surg. 2024 Sep 3. doi: 10.1097/SLA.0000000000006521. https://pubmed.ncbi.nlm.nih.gov/39225420/

Harrison JM, Visser BC. Not Dead Yet: Managing the Abdominal Catastrophe in Necrotizing Pancreatitis. Pancreas. 2025 May 20. doi: 10.1097/MPA.0000000000002512. https://pubmed.ncbi.nlm.nih.gov/40388698/

Harrison JM, Li AY, Sceats LA, Bergquist JR, Dua MM, Visser BC. Two-Port Minimally Invasive Nephrolaparoscopic Retroperitoneal Debridement for Pancreatic Necrosis. J Am Coll Surg. 2024 Dec 1;239(6):e7-e12. doi: 10.1097/XCS.0000000000001152. https://pubmed.ncbi.nlm.nih.gov/39051721/

van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, van Goor H, Schaapherder AF, van Eijck CH, Bollen TL, van Ramshorst B, Nieuwenhuijs VB, Timmer R, Laméris JS, Kruyt PM, Manusama ER, van der Harst E, van der Schelling GP, Karsten T, Hesselink EJ, van Laarhoven CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP, van Leeuwen MS, Buskens E, Gooszen HG; Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010 Apr 22;362(16):1491-502. doi: 10.1056/NEJMoa0908821. https://pubmed.ncbi.nlm.nih.gov/20410514/

Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, Feranec N, Wilcox CM, Tharian B, Hawes RH, Varadarajulu S. An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis. Gastroenterology. 2019 Mar;156(4):1027-1040.e3. doi: 10.1053/j.gastro.2018.11.031. https://pubmed.ncbi.nlm.nih.gov/30452918/

Zyromski NJ, Nakeeb A, House MG, Jester AL. Transgastric Pancreatic Necrosectomy: How I Do It. J Gastrointest Surg. 2016 Feb;20(2):445-9. doi: 10.1007/s11605-015-3058-y. https://pubmed.ncbi.nlm.nih.gov/26691148/

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