Clinical question: Is drainage within 24 hours of diagnosis of infected necrotizing pancreatitis superior at preventing complications?
Background: Diagnosis of infected necrotizing pancreatitis often leads to invasive intervention. Treatment guidelines support a minimally invasive approach and withholding antibiotics until necrosis is encapsulated to prevent unnecessary procedures and complications. Yet, early catheter drainage remains a subject of debate.
Study design: Randomized controlled trial.
Setting: Conducted in 22 centers associated with the Dutch Pancreatitis Study Group.
Synopsis: The 104 patients with confirmed or suspected infected necrotizing pancreatitis with <35 days of symptoms and no prior interventions were randomized to immediate catheter drainage or delayed intervention. All were treated with antibiotics and supportive care. The primary endpoint was the Comprehensive Complication Index score (0: asymptomatic, 100: death) at a 6-month follow-up. Scores were 57 and 58 in the respective groups (mean difference -1 (95% CI -12 to 10; P=0.90). Secondary endpoints of mortality, mean number of interventions, and adverse events were similar without significant differences. Of the postponed drainage group, 39% did not require intervention.
Bottom line: An immediate drainage strategy in patients with infected necrotizing pancreatitis did not improve primary or secondary outcomes and resulted in more procedures compared to a postponed drainage group.
Citation: Boxhoorn, L et al. Immediate versus postponed intervention for infected necrotizing pancreatitis. N Engl J Med 2021; 385:1375-81.
Dr. Berry is an assistant professor of medicine at the University of Colorado School of Medicine hospital medicine section, Rocky Mountain Regional VA Medical Center, Aurora, Colo.