article218

PANTER

"Minimally Invasive Step-Up Approach Versus Open Necrosectomy in Necrotizing Pancreatitis".The New England Journal of Medicine. 2010. 362:1491-1502.PubMed•Full text•PDF

Clinical Question

Does a minimally invasive step-up approach to necrotizing pancreatitis with infected necrotic tissue improve outcomes compared to open necrosectomy?

Bottom Line

In patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue, a minimally invasive step-up approach reduced the rate of major complications or death, as well as long-term complications, health care resource utilization, and total costs, compared to primary open necrosectomy.

Major Points

Necrotizing pancreatitis, often leading to infection and sepsis, is associated with high morbidity and mortality. The traditional treatment, open necrosectomy, is highly invasive and may cause further complications. Studies suggest that a less invasive step-up approach, utilizing percutaneous drainage followed by minimally invasive retroperitoneal necrosectomy only if necessary, may reduce complications and resource utilization.

Guidelines

Current guidelines suggest using a minimally invasive approach to the treatment of necrotizing pancreatitis with suspected or confirmed secondary infection.

Design

Multicenter, randomized, controlled trial.

Population

88 patients with necrotizing pancreatitis and suspected/confirmed infected necrotic tissue.

Inclusions:
- Acute pancreatitis with signs of pancreatic or peripancreatic necrosis on contrast-enhanced CT.
- Confirmed or suspected infected necrosis.
- Decision made to perform a surgical intervention, and possibility for percutaneous or endoscopic drainage.

Exclusions:
- Flare-up of chronic pancreatitis.
- Previous surgeries or interventions for the current episode.
- Pancreatitis due to abdominal surgery.
- Acute intraabdominal events necessitating surgery.

Interventions

Patients were randomized to either:
- Primary open necrosectomy (n=45)
- Minimally invasive step-up approach (n=43): consisting of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy.

Outcomes

Primary Outcome:
- Composite of major complications (new-onset multiple organ failure, multiple systemic complications, organ/enterocutaneous fistula perforation, intraabdominal bleeding) or death: 40% in the step-up group vs. 69% in the open necrosectomy group (risk ratio 0.57; 95% CI, 0.38 to 0.87; P=0.006).

Secondary Outcomes:
- New-onset multiple-organ failure occurred less in the step-up approach (12% vs. 40%, P=0.002).
- Death rates did not differ significantly (19% vs. 16%, P=0.70).
- Incisional hernias and new-onset diabetes were lower in the step-up group (P=0.03 and P=0.02, respectively).
- Health care resource utilization for operations was lower (P=0.004), and costs were 12% less in the step-up approach.

Criticisms

The study did not have sufficient power to detect a significant difference in mortality rates between the two strategies.

Funding

Dutch Organization for Health Research and Development.