Immediate Drainage Not Superior in Patients With Infected Necrotizing Pancreatitis

By Reuters Staff

October 07, 2021

(Reuters Health) - Immediately draining an infected necrotizing pancreas does not prevent complications any better than postponing the procedure, according to a new test in 104 patients reported in the New England Journal of Medicine.

Immediate drainage produced a complication score of 57 while delayed drainage produced a mean score of 58 on a 100-point index where higher numbers reflected more complications.

The research team also found a non-significant difference in the risk of death. Mortality was 13% when drainage was done immediately versus 10% when it was postponed.

In addition, patients in the delayed-drainage group received fewer invasive interventions, said the researchers behind the POINTER study. However, again, the difference was not significant.

"These findings suggest that an initial conservative approach with antibiotics is justified when infected necrosis is diagnosed," writes the research team, led by Dr. Lotte Boxhoorn of Amsterdam UMC, University of Amsterdam, in The Netherlands.

Doctors have been divided on the best time to drain. An international survey of pancreatologists from 2016 found that 45% endorsed early drainage once infected pancreatic and peripancreatic necrosis was diagnosed.

To study the question, the team of doctors recruited volunteers treated at 22 Dutch centers. All were eligible for image-guided percutaneous or endoscopic transluminal drainage for their infected necrotizing pancreatitis. All had developed their acute pancreatitis within the previous 35 days. All were treated with antibiotics.

Patients in the immediate-drainage group received catheterization within 24 hours after randomization, with randomization occurring as soon as infected necrosis was diagnosed. In the other group, doctors tried to postpone drainage until the necrosis was largely or fully encapsulated. Drainage was undertaken if the patient's clinical condition deteriorated.

When drainage occurred, the necrosis was fully or largely encapsulated in 60% of the patients who got their drainage immediately versus 70% of those assigned to the delayed-drainage group.

The researchers also found no difference between the two groups in the rates of new-onset organ failure, the risk of bleeding, wound infection, length of hospital stay, length of intensive care unit stay, the risk of pancreaticocutaneous fistula, or the odds of visceral organ perforation, enterocutaneous fistula, or both.

However, the mean number of surgical, radiologic, or endoscopic interventions during follow-up was 4.4 with immediate drainage compared with 2.6 with postponed drainage.

"At the 6-month follow-up, there were no between-group differences in development of endocrine and exocrine pancreatic insufficiency or in total inpatient hospital costs," the researchers write.

"Patients randomly assigned to the immediate-drainage group 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," they note.

In the delayed drainage group 35% of patients never needed drainage at all because antibiotic therapy alone was the only treatment they needed.

However, "in case of rapid clinical deterioration, early catheter drainage is a valid treatment option," they write.

Corresponding author Marc G. Besselink of Amsterdam UMC did not respond to emails seeking comment.

SOURCE: https://bit.ly/3FfxMdh The New England Journal of Medicine, online October 6, 2021.

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