Upfront necrosectomy reduces reinterventions in infected necrotizing pancreatitis
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Key takeaways:
- Upfront endoscopic necrosectomy significantly reduced the number of reinterventions needed for treatment success vs. a step-up approach.
- Treatment success was high among patients in both groups.
Upfront endoscopic necrosectomy performed at the index intervention resulted in fewer reinterventions compared with a step-up treatment approach among patients with infected necrotizing pancreatitis and fully encapsulated collections.
“Although the traditional treatment approach to infected necrotizing pancreatitis has been open surgical necrosectomy, the technique is associated with high rates of adverse events (34%-95%) and death (11%-39%),” Ji Young Bang, MD, of the Digestive Health Institute at Orlando Health, and colleagues wrote in The Lancet Gastroenterology & Hepatology. “To improve morbidity and mortality, a step-up approach has been incorporated into clinical practice ... However, the endoscopic step-up approach, as with surgery, by virtue of its treatment design, is associated with the need for multiple reinterventions and prolonged hospitalization and, therefore, the optimal treatment approach remains unclear.”
To compare outcomes of upfront necrosectomy vs. a step-up approach, Bang and colleagues conducted a single-blinded, multicenter randomized trial of 70 adults with confirmed or suspected infected necrotizing pancreatitis. Participants had a necrosis extent of at least 33% and were amenable to endoscopic ultrasound-guided drainage.
Between November 2019 and October 2022, 37 patients underwent direct endoscopic necrosectomy immediately after stenting and 33 patients underwent direct necrosectomy or additional drainage at a subsequent treatment session, if no clinical improvement was reported 72 hours after stenting. Researchers noted 91% of participants had walled-off necrosis at baseline and 10% had organ failure.
The primary outcome was the number of reinterventions needed to achieve treatment success from index intervention to 6 months, defined as symptom relief with disease resolution.
According to results, the median number of reinterventions was significantly lower in the upfront group compared with the step-up group (1 vs. 2; difference = –1; 95% CI, –2 to 0), and clinical improvement 72 hours after index intervention was significantly higher (76% vs. 52%; difference = 24.2 percentage points; 95% CI, 1.4-44.4). However, researchers reported high overall treatment success in both groups (100% vs. 94%; difference = 6.1 percentage points; 95% CI, –4.5 to 16.5).
Further, upfront necrosectomy was associated with shorter hospital stay (9 vs. 19 days; difference = –5; 95% CI, –13 to 0) as well as lower mean adjusted overall treatment cost ($576,182 vs. $847,567).
There were no significant differences between groups in mortality (0% vs. 6%; difference = –6.1 percentage points; 95% CI, –16.5 to 4.5), overall disease-related adverse events (32% vs. 48%; difference = –16.1 percentage points; 95% CI, –37.4 to 7) or procedure-related adverse events (11% vs. 24%; difference = –13.4 percentage points; 95% CI, –30.8 to 5).
“An approach incorporating upfront endoscopic necrosectomy, as compared with a step-up approach, significantly reduced the number of reinterventions to achieve treatment success,” Bang and colleagues wrote. “Although we found no significant difference in treatment success and adverse events, such an approach could expedite clinical recovery, minimize the need for reinterventions and shorten the length of hospital stay and, thereby, reduce health care costs.”
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