Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines

Abstract

1: ESGE suggests using contrast-enhanced computed tomography (CT) as the first-line imaging modality on admission when indicated and up to the 4th week from onset in the absence of contraindications. Magnetic resonance imaging (MRI) may be used instead of CT in patients with contraindications to contrast-enhanced CT, and after the 4th week from onset when invasive intervention is considered because the contents (liquid vs. solid) of pancreatic collections are better characterized by MRI and evaluation of pancreatic duct integrity is possible. Weak recommendation, low quality evidence. 2: ESGE recommends against routine percutaneous fine needle aspiration (FNA) of (peri)pancreatic collections. Strong recommendation, moderate quality evidence. FNA should be performed only if there is suspicion of infection and clinical/imaging signs are unclear. Weak recommendation, low quality evidence. 3: ESGE recommends initial goal-directed intravenous fluid therapy with Ringer's lactate (e. g. 5 - 10 mL/kg/h) at onset. Fluid requirements should be patient-tailored and reassessed at frequent intervals. Strong recommendation, moderate quality evidence. 4: ESGE recommends against antibiotic or probiotic prophylaxis of infectious complications in acute necrotizing pancreatitis. Strong recommendation, high quality evidence. 5: ESGE recommends invasive intervention for patients with acute necrotizing pancreatitis and clinically suspected or proven infected necrosis. Strong recommendation, low quality evidence.ESGE suggests that the first intervention for infected necrosis should be delayed for 4 weeks if tolerated by the patient. Weak recommendation, low quality evidence. 6: ESGE recommends performing endoscopic or percutaneous drainage of (suspected) infected walled-off necrosis as the first interventional method, taking into account the location of the walled-off necrosis and local expertise. Strong recommendation, moderate quality evidence. 7: ESGE suggests that, in the absence of improvement following endoscopic transmural drainage of walled-off necrosis, endoscopic necrosectomy or minimally invasive surgery (if percutaneous drainage has already been performed) is to be preferred over open surgery as the next therapeutic step, taking into account the location of the walled-off necrosis and local expertise. Weak recommendation, low quality evidence. 8: ESGE recommends long-term indwelling of transluminal plastic stents in patients with disconnected pancreatic duct syndrome. Strong recommendation, low quality evidence. Lumen-apposing metal stents should be retrieved within 4 weeks to avoid stent-related adverse effects.Strong recommendation, low quality evidence.

Conflict of interest statement

J. Albert has received speaker’s honoraria from Fujifilm (2015 – 2016), Falk foundation, and Covidien/Medtronic (2015 – 2017), and both research and speaker’s honoraria from Olympus Europe (2015 – 2017). A. Badaoui received a travel grant from Boston Scientific (2016). M. Barthet is a consultant for and receives research support from Boston Scientific (2016 to present). J. Devière has received research support from Cook Medical (until 2016) and from Boston Scientific (ongoing); his department is receiving research support from Olympus (ongoing). I. Hritz is a consultant (speaker/tutor) for Olympus Europe (ongoing). I. Papanikolaou is co-editor for social media with the Endoscopy journal. J.-W. Poley has received consultancy, travel, and speaker’s fees from Cook Endoscopy and Boston Scientific (ongoing). S. Seewald has received consultancy fees from Boston Scientific (until 2016), and from Olympus and Cook Medical (ongoing). J. van Hooft received lecture fees from Medtronics (2014 – 2015) and a consultancy fee from Boston Scientific (2014 – 2016); her department received research grants from Cook Medical and Abbott (2014 – 2017). K. van Lienden is receiving consultancy and speaker’s fees from Cook Medical (ongoing). M. Arvanitakis, M. A. Bali, M. Besselink, M. Delhaye, J.-M. Dumonceau, A. Ferreira, T. Gyökeres, T. Hucl, M. Milashka, H. van Santvoort, G. Vanbiervliet, and R. Voermans have no competing interests.

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