Approach to the Diagnosis and Management of Infected Pancreatic Necrosis: A Narrative Review.

Infected pancreatic necrosis (IPN) is a dreaded complication of acute necrotizing pancreatitis and is linked to persistent organ failure, sepsis, and increased morbidity and mortality. Clinical indicators of IPN include fever, clinical deterioration, and worsening inflammatory markers. The diagnosis of IPN is based on clinical signs, microbiological confirmation, and radiological evidence, with contrast-enhanced CT being the preferred imaging modality. In the absence of tests with high sensitivity, a high clinical suspicion is required for early recognition and treatment. Although there is no way to prevent IPN, a systematic management approach with parenteral antibiotics, nutritional management, and minimally invasive procedures has become the cornerstone of the treatment. The step-up approach includes minimally invasive procedures that minimize procedure-related complications and are associated with improved outcomes. The percutaneous route remains the most common route for drainage, while endoscopic interventions are preferred for perigastric or periduodenal encapsulated collections. The use of lumen-apposing metal stents is associated with excellent outcomes in cases of infected walled-off necrosis. Patients with significant quantities of infected necrosis may benefit from direct or percutaneous endoscopic necrosectomy. Minimally invasive surgical techniques followed by open surgeries are reserved for patients who do not improve with percutaneous or endoscopic necrosectomies. The outcome can be maximized through a multidisciplinary approach by a team of interventional radiologists, advanced therapeutic endoscopists, and surgeons.