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A Step-up Approach or Open Necrosectomy for Necrotizing Pancreatitis

van Santvoort, H. C., Besselink, M. G., Bakker, O. J., Hofker, H. S., Boermeester, M. A., Dejong, C. H., van Goor, H., Schaapherder, A. F., van Eijck, C. H., Bollen, T. L., van Ramshorst, B., Nieuwenhuijs, V. B., Timmer, R., Lameris, J. S., Kruyt, P. M., Manusama, E. R., van der Harst, E., van der Schelling, G. P., Karsten, T., Hesselink, E. J., van Laarhoven, C. J., Rosman, C., Bosscha, K., de Wit, R. J., Houdijk, A. P., van Leeuwen, M. S., Buskens, E., Gooszen, H. G. & Dutch Pancreatitis Study Grp, 22-Apr-2010, In : New England Journal of Medicine. 362, 16, p. 1491-1502 12 p.

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DOI

  • Hjalmar C. van Santvoort
  • Marc G. Besselink
  • Olaf J. Bakker
  • H. Sijbrand Hofker
  • Marja A. Boermeester
  • Cornelis H. Dejong
  • Harry van Goor
  • Alexander F. Schaapherder
  • Casper H. van Eijck
  • Thomas L. Bollen
  • Bert van Ramshorst
  • Vincent B. Nieuwenhuijs
  • Robin Timmer
  • Johan S. Lameris
  • Philip M. Kruyt
  • Eric R. Manusama
  • Erwin van der Harst
  • George P. van der Schelling
  • Tom Karsten
  • Eric J. Hesselink
  • Cornelis J. van Laarhoven
  • Camiel Rosman
  • Koop Bosscha
  • Ralph J. de Wit
  • Alexander P. Houdijk
  • Maarten S. van Leeuwen
  • Erik Buskens
  • Hein G. Gooszen
  • Dutch Pancreatitis Study Grp

BACKGROUND

Necrotizing pancreatitis with infected necrotic tissue is associated with a high rate of complications and death. Standard treatment is open necrosectomy. The outcome may be improved by a minimally invasive step-up approach.

METHODS

In this multicenter study, we randomly assigned 88 patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue to undergo primary open necrosectomy or a step-up approach to treatment. The step-up approach consisted of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy. The primary end point was a composite of major complications (new-onset multiple-organ failure or multiple systemic complications, perforation of a visceral organ or enterocutaneous fistula, or bleeding) or death.

RESULTS

The primary end point occurred in 31 of 45 patients (69%) assigned to open necrosectomy and in 17 of 43 patients (40%) assigned to the step-up approach (risk ratio with the step-up approach, 0.57; 95% confidence interval, 0.38 to 0.87; P = 0.006). Of the patients assigned to the step-up approach, 35% were treated with percutaneous drainage only. New-onset multiple-organ failure occurred less often in patients assigned to the step-up approach than in those assigned to open necrosectomy (12% vs. 40%, P = 0.002). The rate of death did not differ significantly between groups (19% vs. 16%, P = 0.70). Patients assigned to the step-up approach had a lower rate of incisional hernias (7% vs. 24%, P = 0.03) and new-onset diabetes (16% vs. 38%, P = 0.02).

CONCLUSIONS

A minimally invasive step-up approach, as compared with open necrosectomy, reduced the rate of the composite end point of major complications or death among patients with necrotizing pancreatitis and infected necrotic tissue. (Current Controlled Trials number, ISRCTN13975868.)

Original languageEnglish
Pages (from-to)1491-1502
Number of pages12
JournalNew England Journal of Medicine
Volume362
Issue number16
Publication statusPublished - 22-Apr-2010

    Keywords

  • ENDOSCOPIC NECROSECTOMY, SURGICAL INTERVENTION, NECROSIS, MANAGEMENT, DEBRIDEMENT, GUIDELINES, DRAINAGE, PATIENT, LAVAGE

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