American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis

DescriptionThe purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition.MethodsThis expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis.Best Practice Advice 1Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center.Best Practice Advice 2Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended.Best Practice Advice 3When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography–guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases.Best Practice Advice 4In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated.Best Practice Advice 5Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome.Best Practice Advice 6Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication.Best Practice Advice 7Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula.Best Practice Advice 8Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden.Best Practice Advice 9Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis.Best Practice Advice 10The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup.Best Practice Advice 11Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity.Best Practice Advice 12Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources.Best Practice Advice 13Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures.Best Practice Advice 14For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting.Best Practice Advice 15A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise. The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition. This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis. Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center. Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended. When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography–guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases. In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated. Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication. Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula. Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden. Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis. The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup. Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity. Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources. Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures. For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting. A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise. Acute pancreatitis is one of the most common gastrointestinal illnesses encountered in clinical practice. The majority of cases are mild, self-limited, and follow an uncomplicated course. However, 10%–20% of cases can be associated with necrosis of the pancreatic gland, peripancreatic tissue, or both. This subset of patients may face a complex, prolonged clinical course, with associated mortality of up to 20%–30% if infection develops in the necrotic collection.1Trikudanathan G. Wolbrink D.R.J. van Santvoort H.C. et al.Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach.Gastroenterology. 2019; 156: 1994-2007 e3Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar Successful management of these patients requires expert multidisciplinary care by gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. Over the past decade, there has been progress and improvement in understanding disease presentation and natural history. An expert consensus panel reclassified how pancreatic fluid collections are defined, noting the importance of not only the length of time a pancreatic fluid collection has been present, but also its contents (Supplementary Figure 1).2Banks P.A. Bollen T.L. Dervenis C. et al.Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus.Gut. 2013; 62: 102-111Crossref PubMed Scopus (3523) Google Scholar Similarly, approaches to managing necrotizing pancreatitis have evolved. Whereby major surgical intervention and debridement were once the mainstay of therapy for patients with symptomatic necrotic collections, a minimally invasive approach focusing on percutaneous drainage and/or endoscopic drainage or debridement is now favored. There is general agreement that drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis, as this group carries the highest risk of death. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure, or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. However, management of patients with pancreatic necrosis depends on other critical 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. Evidence-based guidelines on the management of acute pancreatitis reported that Grade 1A evidence exists to support an initial minimally invasive drainage approach to infected walled-off pancreatic necrosis (WON), but only Grade 1C evidence in terms of appropriate indications and timing of interventions and Grade 2C evidence for intervention in sterile necrosis.3Working Group IAP/APA Acute Pancreatitis GuidelinesIAP/APA evidence-based guidelines for the management of acute pancreatitis.Pancreatology. 2013; 13: e1-e15Crossref PubMed Scopus (1124) Google Scholar Moderate-strength evidence exists pertaining to various aspects of antibiotics, nutrition, and intravenous fluids, and as such, variability exists among practitioners and institutions regarding the preferred management approach. We refer the reader to the American Gastroenterological Association Technical Review4Vege S.S. DiMagno M.J. Forsmark C.E. et al.Initial Medical treatment of acute pancreatitis: American Gastroenterological Association Institute Technical Review.Gastroenterology. 2018; 154: 1103-1139Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar and Guideline5Crockett S.D. Wani S. Gardner T.B. et al.American Gastroenterological Association Institute Guideline on Initial Management of Acute Pancreatitis.Gastroenterology. 2018; 154: 1096-1101Abstract Full Text Full Text PDF PubMed Scopus (367) Google Scholar on the “Initial Medical Treatment of Acute Pancreatitis” for management at the onset and in the earliest phase of this disease, and to a recent systematic review published in this journal that comprehensively discusses the recent data and technical aspects of caring for patients with severe acute and necrotizing pancreatitis.1Trikudanathan G. Wolbrink D.R.J. van Santvoort H.C. et al.Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach.Gastroenterology. 2019; 156: 1994-2007 e3Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar The purpose of this American Gastroenterological Association Clinical Practice Update was to review the available evidence and expert recommendations regarding the management of pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition. Infection of pancreatic necrosis is associated with mortality rates as high as 30%. Therefore, in the management of pancreatic necrosis much attention is given to prevention of infection, as well as treatment of suspected or confirmed infection. Infected necrosis should be suspected when cross-sectional imaging demonstrates gas in a pancreatic or peripancreatic collection. Other factors that may be indicative of infected necrosis include the presence of fevers, bacteremia, worsening leukocytosis, persistent unwellness, or clinical deterioration. Many of these factors can be seen in the setting of systemic inflammatory response syndrome, ongoing pancreatitis, or cholangitis, and thus distinguishing infected necrosis from these other conditions can be difficult based on clinical parameters alone. When infected necrosis is suspected, initiation of broad-spectrum intravenous antibiotics with good penetration into the pancreas is recommended. These include carbapenems, quinolones, metronidazole, and third- or higher-generation cephalosporins. Computed tomography–guided percutaneous biopsies of necrotic collections with samples sent for Gram stain and cultures can be performed to confirm the presence of infection. However, this is unnecessary in the vast majority of cases. In addition, false-negative results are possible, and there is a theoretical risk of contaminating a sterile collection. One scenario where computed tomography–guided biopsy/aspiration may help is for guidance in antibiotic selection, for example, in a patient with suspected infected necrosis but continued deterioration despite antibiotic administration. Much debate exists as to the role of antibiotics in the prevention of infected necrosis. However, multiple prospective, randomized, placebo-controlled trials have demonstrated that in patients with severe acute necrotizing pancreatitis, the administration of prophylactic broad-spectrum antibiotics has no impact on rates of developing infected necrosis, systemic complications, mortality, or need for surgical intervention.6Isenmann R. Runzi M. Kron M. et al.Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial.Gastroenterology. 2004; 126: 997-1004Abstract Full Text Full Text PDF PubMed Scopus (418) Google Scholar, 7Dellinger E.P. Tellado J.M. Soto N.E. et al.Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study.Ann Surg. 2007; 245: 674-683Crossref PubMed Scopus (283) Google Scholar, 8Garcia-Barrasa A. Borobia F.G. Pallares R. et al.A double-blind, placebo-controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis.J Gastrointest Surg. 2009; 13: 768-774Crossref PubMed Scopus (72) Google Scholar Furthermore, there is a lack of evidence to support prophylactic use of antifungal therapy in patients with pancreatic necrosis, and thus routine administration is not recommended. The role of nutrition has generated intense debate over the past few decades. It was generally believed that patients with acute pancreatitis would be at risk for a worsening clinical course if the pancreas was stimulated by oral or enteral nutrition, and would benefit from “pancreatic rest” by receiving total parenteral nutrition (TPN) and remaining nil per os. However, these theories have been largely disproven. Most patients with severe and/or necrotizing pancreatitis are acutely ill, in a hypercatabolic state, and subject to a multitude of metabolic and systemic derangements. The gastrointestinal tract is subject to decreased mucosal integrity with subsequent increase in gut permeability, as well as decreased gut motility and increased risk of bacterial overgrowth. This combination of factors can result in increased bacterial translocation and a higher risk of infected pancreatic necrosis. Administration of enteral feeds can mitigate these effects. For patients without nausea, vomiting, or evidence of intestinal obstruction or ileus, a trial of oral nutrition should be commenced immediately. For patients unable to tolerate oral intake, early nutritional support should be prioritized within the first 24–72 hours (Figure 1). Numerous studies have demonstrated that early initiation of enteral nutrition in patients with severe pancreatitis is associated with significantly improved outcomes. In a prospective randomized study, Petrov et al9Petrov M.S. Kukosh M.V. Emelyanov N.V. A randomized controlled trial of enteral versus parenteral feeding in patients with predicted severe acute pancreatitis shows a significant reduction in mortality and in infected pancreatic complications with total enteral nutrition.Dig Surg. 2006; 23 (discussion 344–345): 336-344Crossref PubMed Scopus (188) Google Scholar demonstrated that patients receiving total enteral nutrition (TEN) had significantly lower rates of pancreatic infectious complications (20% vs 47%), multiorgan failure (20% vs 50%), and death (6% vs 35%) compared to patients receiving TPN. Similarly, Wu et al10Wu X.M. Ji K.Q. Wang H.Y. et al.Total enteral nutrition in prevention of pancreatic necrotic infection in severe acute pancreatitis.Pancreas. 2010; 39: 248-251Crossref PubMed Scopus (64) Google Scholar demonstrated that TEN was associated with significantly lower rates of organ failure (21% vs 80%), multiorgan failure (15% vs 65%), need for surgery (22% vs 80%), septic pancreatic necrosis (23% vs 72%), and mortality (11% vs 43%) compared to TPN. While it is clear that TEN is the preferred type of nutritional support for patients with severe pancreatitis, debate remains about the preferred route of administration. A number of small, prospective, randomized studies demonstrated that nasogastric feeding was not inferior to nasojejunal feeding in terms of infectious complications, pain, inflammatory markers, or analgesia requirements.11Singh N. Sharma B. Sharma M. et al.Evaluation of early enteral feeding through nasogastric and nasojejunal tube in severe acute pancreatitis: a noninferiority randomized controlled trial.Pancreas. 2012; 41: 153-159Crossref PubMed Scopus (106) Google Scholar,12Eatock F.C. Chong P. Menezes N. et al.A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis.Am J Gastroenterol. 2005; 100: 432-439Crossref PubMed Scopus (331) Google Scholar Therefore, either route is acceptable, although nasogastric (or nasoduodenal) tubes are easier to place and maintain. For those patients in whom nasoenteric feeding is not tolerated (eg, due to nasal irritation) and/or in whom long-term TEN is anticipated (>30 days), endoscopic placement of a feeding tube should be considered. Patients who are able to tolerate nasogastric tube feeds are candidates for a percutaneous endoscopic gastrostomy tube. For those patients who are unable to tolerate gastric feeds and/or who are at high risk for aspiration, a direct percutaneous endoscopic jejunostomy tube is a reasonable option. For those patients with gastric outlet obstruction, delayed gastric emptying, and/or prolonged ileus, placement of a percutaneous endoscopic gastrostomy tube with jejunal extension enables on-demand gastric decompression in addition to providing downstream enteral nutrition. Despite the advantages of TEN, there remains a role for TPN in patients with severe pancreatitis. Patients who are unable to tolerate TEN due to luminal obstruction or severe dysmotility, who cannot tolerate a nasal tube and have a problem (eg, leak or infection) at a percutaneous feeding tube site, or who are unable to reach their goal caloric needs via the enteral route, should be considered for TPN. Percutaneous drainage, alone or in combination with other minimally invasive approaches, remains an important treatment modality for patients with symptomatic WON. Percutaneous drainage can provide a rapid and effective means for source control in patients with infected pancreatic necrosis who are too ill to undergo endoscopic transmural drainage. Percutaneous drainage monotherapy may provide definitive therapy for a subset of patients. A large prospective, multicenter, observational, cohort study demonstrated that, in the subgroup of patients managed by primary percutaneous catheter drainage, 35% did not require further intervention.13van Santvoort H.C. Bakker O.J. Bollen T.L. et al.A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome.Gastroenterology. 2011; 141: 1254-1263Abstract Full Text Full Text PDF PubMed Scopus (416) Google Scholar Two prospective randomized trials comparing various approaches to the management of symptomatic WON demonstrated that percutaneous drainage alone was successful in 35% and 51% of patients, respectively.14van Santvoort H.C. Besselink M.G. Bakker O.J. et al.A step-up approach or open necrosectomy for necrotizing pancreatitis.N Engl J Med. 2010; 362: 1491-1502Crossref PubMed Scopus (996) Google Scholar,15van Brunschot S. van Grinsven J. van Santvoort H.C. et al.Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial.Lancet. 2018; 391: 51-58Abstract Full Text Full Text PDF PubMed Scopus (326) Google Scholar Percutaneous drainage should be employed when endoscopic drainage is unavailable, unsuccessful, or not technically feasible. In cases where necrosis extends into one or both paracolic gutters and/or into the pelvis, the dependent portions of the collection will not be able to drain effectively through superiorly located transmural endoscopic stents. Percutaneous catheter placement into the retroperitoneum and/or pelvis will not only facilitate drainage of these dependent areas, but also allows for bedside irrigation and clearance of necrotic material. Multiple large series have demonstrated that the adjunctive use of percutaneous drainage catheters (ranging in size from 8F to 24F) in patients undergoing endoscopic drainage and debridement can result in improved outcomes.16Nemoto Y. Attam R. Arain M.A. et al.Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: outcomes in a large cohort of patients.Pancreatology. 2017; 17: 663-668Crossref PubMed Scopus (29) Google Scholar, 17Bang J.Y. Holt B.A. Hawes R.H. et al.Outcomes after implementing a tailored endoscopic step-up approach to walled-off necrosis in acute pancreatitis.Br J Surg. 2014; 101: 1729-1738Crossref PubMed Scopus (38) Google Scholar, 18Ross A.S. Irani S. Gan S.I. et al.Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes.Gastrointest Endosc. 2014; 79: 929-935Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar Another major advantage to the use of percutaneous drainage catheters is that the catheter tract can act as an entry portal for other minimally invasive debridement methods, such as video-assisted retroperitoneal debridement or endoscopic sinus tract debridement. A 24F or larger percutaneous drain reduces the need for dissection at the time of video-assisted retroperitoneal debridement (VARD). Lastly, for patients in the early phase of acute necrotizing pancreatitis (<2–4 weeks) who have suspected or confirmed infected necrosis—without the presence of a walled-off collection—and are failing conservative medical management, percutaneous drainage can provide safe and effective