Clinical Pearls & Morning Reports
Infected necrotizing pancreatitis is a potentially lethal disease that is treated with the use of a step-up approach, with catheter drainage often delayed until the infected necrosis is encapsulated. Whether outcomes could be improved by earlier catheter drainage is unknown. Boxhoorn et al. conducted a randomized trial that investigated whether immediate catheter drainage was superior to postponed catheter drainage in patients with infected necrotizing pancreatitis. Read the NEJM Original Article here.
Q: What percentage of patients with acute pancreatitis develop necrotizing pancreatitis?
A: Acute pancreatitis is the most common pancreatic disease worldwide. Necrotizing pancreatitis develops in approximately 20 to 30% of patients with acute pancreatitis. Pancreatic and peripancreatic necrosis that becomes infected nearly always leads to invasive intervention.
Q: What is the current standard approach for the treatment of infected necrotizing pancreatitis?
A: The current standard approach for infected necrotizing pancreatitis is a minimally invasive step-up approach with catheter drainage as the first step. International guidelines advise postponement of catheter drainage and administration of antibiotics until the infected pancreatic and peripancreatic necrosis has become encapsulated; such walled-off necrosis usually takes 4 weeks to develop. One rationale for postponement of an invasive intervention is to prevent complications, but this rationale originated from the era when open surgical necrosectomy was performed, and postponement may be less important for minimally invasive interventions.
A: The trial’s results do not support the hypothesis that catheter drainage performed immediately after diagnosis of infected necrosis leads to better patient outcomes with fewer complications than postponed drainage. The primary end point was the score on the Comprehensive Complication Index, which incorporates all complications over the course of 6 months of follow-up. The authors found no difference between the groups in the primary end point: the mean Comprehensive Complication Index score was 57 in the immediate-drainage group and 58 in the postponed-drainage group (mean difference, −1; 95% CI, −12 to 10; P=0.90). Mortality was 13% in the immediate-drainage group, as compared with 10% in the postponed-drainage group (relative risk, 1.25; 95% CI, 0.42 to 3.68). Length of stay in the intensive care unit did not differ between the groups.
A: Patients randomly assigned to the immediate-drainage strategy underwent more interventions for infected necrosis, whereas the postponed-drainage strategy averted the need for intervention in more than one third of the patients assigned to that group. Specifically, the mean number of surgical, endoscopic, and radiologic interventions (catheter drainage and necrosectomy) was higher in the immediate-drainage group than in the postponed-drainage group (4.4 vs. 2.6; mean difference, 1.8; 95% CI, 0.6 to 3.0). In the postponed-drainage group, 19 patients (39%) were treated conservatively with antibiotics alone (without the need for drainage or necrosectomy); 17 of these patients survived.