Direct endoscopic necrosectomy reduced reinterventions in necrotizing pancreatitis
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CHICAGO — Immediate direct endoscopic necrosectomy significantly reduced the number of reinterventions and decreased length of hospital stay compared with a step-up approach in patients with infected necrotizing pancreatitis.
“The mortality in pancreatic necrosis ranges from 8% to 39% with higher rates in the presence of secondary infection,” Ji Young Bang, MD, a gastroenterologist at the Digestive Health Institute Center for Advanced Endoscopy, Research and Education at Orlando Health, told attendees at Digestive Disease Week. “An endoscopic step-up treatment approach is associated with lower rate of adverse events and death compared to minimally invasive surgery, and is the performance of direct endoscopic necrosectomy when there is no clinical improvement after transluminal stent placement. This approach necessitates the need for more interventions and prolonged hospitalization.”
She added: “We hypothesized that if endoscopic necrosectomy is offered as upfront treatment rather than step-up measure, it is likely to reduce reinterventions and expedite clinical recovery and hospital discharge.”
Bang and colleagues conducted a multicenter, randomized trial of 70 patients with confirmed or suspected infected necrotizing pancreatitis who required intervention between November 2019 and October 2022.
Patients underwent direct endoscopic necrosectomy at the index treatment session following lumen-apposing metal stent placement (n = 37) or a step-up approach, with necrosectomy performed only if no clinical improvement was observed after stent placement (n = 33).
The number of reinterventions performed to achieve treatment success — symptom relief with disease resolution via CT at 6 months — served as the primary endpoint. Other outcomes included mortality rate, adverse events, readmissions, length of hospitalization and treatment costs.
According to results, patients who underwent immediate direct endoscopic necrosectomy had significantly lower reinterventions (mean, 0.9) compared with those who received step-up treatment approach (mean, 2.5; P = .001).
Bang and colleagues also noted the overall length of hospital stay was significantly shorter in patients who received direct endoscopic necrosectomy vs. step-up approach (median, 9 days vs. 19 days, P = .048), although differences were not significant in treatment success (94.6% vs. 90.9%), mortality (0% vs. 6.1%), adverse events (45.9% vs. 60.6%) and mean number of readmissions (0.8 vs. 0.8).
“There was also no difference in the postintervention [systemic inflammatory response syndrome] sepsis, organ failure resolution, or endocrine and exocrine function,” Bang noted. “The final outcome measure was that there was no difference in adverse events, neither procedural-related adverse events nor disease-related adverse events, including mortality.”
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Bang JY, et al. Abstract 913c: Direct endoscopic versus step-up transluminal interventions in necrotizing pancreatitis (DESTIN): Results of a randomized trial. Presented at: Digestive Disease Week; May 5-9, 2023; Chicago (hybrid meeting).
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