Janneke van Grinsven

Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial

BACKGROUND Infected necrotising pancreatitis is a potentially lethal disease and an indication for invasive intervention. The surgical step-up approach is the standard treatment. A promising alternative is the endoscopic step-up approach. We compared both approaches to see whether the endoscopic step-up approach was superior to the surgical step-up approach in terms of clinical and economic outcomes. METHODS In this multicentre, randomised, superiority trial, we recruited adult patients with infected necrotising pancreatitis and an indication for invasive intervention from 19 hospitals in the Netherlands. Patients were randomly assigned to either the endoscopic or the surgical step-up approach. The endoscopic approach consisted of endoscopic ultrasound-guided transluminal drainage followed, if necessary, by endoscopic necrosectomy. The surgical approach consisted of percutaneous catheter drainage followed, if necessary, by video-assisted retroperitoneal debridement. The primary endpoint was a composite of major complications or death during 6-month follow-up. Analyses were by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN09186711. FINDINGS Between Sept 20, 2011, and Jan 29, 2015, we screened 418 patients with pancreatic or extrapancreatic necrosis, of which 98 patients were enrolled and randomly assigned to the endoscopic step-up approach (n=51) or the surgical step-up approach (n=47). The primary endpoint occurred in 22 (43%) of 51 patients in the endoscopy group and in 21 (45%) of 47 patients in the surgery group (risk ratio [RR] 0·97, 95% CI 0·62-1·51; p=0·88). Mortality did not differ between groups (nine [18%] patients in the endoscopy group vs six [13%] patients in the surgery group; RR 1·38, 95% CI 0·53-3·59, p=0·50), nor did any of the major complications included in the primary endpoint. INTERPRETATION In patients with infected necrotising pancreatitis, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group. The outcome of this trial will probably result in a shift to the endoscopic step-up approach as treatment preference. FUNDING The Dutch Digestive Disease Foundation, Fonds NutsOhra, and the Netherlands Organization for Health Research and Development.

Endoscopic evaluation of the colon after an episode of diverticulitis: a call for a more selective approach

PurposeRoutine colonic evaluation is advised after an episode of diverticulitis to exclude colorectal cancer. In the recent years, the possible relation between diverticulitis and colorectal cancer has been subject of debate. The aim of this study is to evaluate the benefit of routine colonic endoscopy after an episode of diverticulitis.MethodsRecords of all consecutive patients presenting with a radiologically confirmed episode of diverticulitis between 2007 and 2010 were retrieved from an in-hospital database. Patients who subsequently underwent colonic evaluation were included. The endoscopic detection rate of hyperplastic polyps, adenomas and advanced colonic neoplasia was assessed. Findings were categorized on the basis of the most advanced lesion identified.ResultsThree hundred and seven patients presented with a radiologically confirmed primary episode of diverticulitis. Two hundred and five patients underwent colonic evaluation. Hyperplastic polyps were found in15 (6.8 %), adenomas in 18 (8.8 %) and advanced neoplastic lesions in 7 (3.4 %) patients. Only two patients had a colorectal malignancy.ConclusionThere appears to be no benefit in performing routine colonic evaluation after an episode of diverticulitis as the incidence of colorectal cancer is almost equal to that of the general population. A more selective approach might therefore be justified. Potentially, only patients with persisting abdominal complaints after an episode of diverticulitis should be offered colonic evaluation to definitively exclude causal pathology.

Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: An international expert survey and case vignette study

BACKGROUND The optimal diagnostic strategy and timing of intervention in infected necrotizing pancreatitis is subject to debate. We performed a survey on these topics amongst a group of international expert pancreatologists. METHODS An online survey including case vignettes was sent to 118 international pancreatologists. We evaluated the use and timing of fine needle aspiration (FNA), antibiotics, catheter drainage and (minimally invasive) necrosectomy. RESULTS The response rate was 74% (N = 87). None of the respondents use FNA routinely, 85% selectively and 15% never. Most respondents (87%) use a step-up approach in patients with infected necrosis. Walled-off necrosis (WON) is considered a prerequisite for endoscopic drainage and percutaneous drainage by 66% and 12%, respectively. After diagnosing infected necrosis, 55% routinely postpone invasive interventions, whereas 45% proceed immediately to intervention. Lack of consensus about timing of intervention was apparent on day 14 with proven infected necrosis (58% intervention vs. 42% non-invasive) as well as on day 20 with only clinically suspected infected necrosis (59% intervention vs. 41% non-invasive). DISCUSSION The step-up approach is the preferred treatment strategy in infected necrotizing pancreatitis amongst expert pancreatologists. There is no uniformity regarding the use of FNA and timing of intervention in the first 2-3 weeks of infected necrotizing pancreatitis.

Original articleDiagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an international expert survey and case vignette study

BACKGROUND The optimal diagnostic strategy and timing of intervention in infected necrotizing pancreatitis is subject to debate. We performed a survey on these topics amongst a group of international expert pancreatologists. METHODS An online survey including case vignettes was sent to 118 international pancreatologists. We evaluated the use and timing of fine needle aspiration (FNA), antibiotics, catheter drainage and (minimally invasive) necrosectomy. RESULTS The response rate was 74% (N = 87). None of the respondents use FNA routinely, 85% selectively and 15% never. Most respondents (87%) use a step-up approach in patients with infected necrosis. Walled-off necrosis (WON) is considered a prerequisite for endoscopic drainage and percutaneous drainage by 66% and 12%, respectively. After diagnosing infected necrosis, 55% routinely postpone invasive interventions, whereas 45% proceed immediately to intervention. Lack of consensus about timing of intervention was apparent on day 14 with proven infected necrosis (58% intervention vs. 42% non-invasive) as well as on day 20 with only clinically suspected infected necrosis (59% intervention vs. 41% non-invasive). DISCUSSION The step-up approach is the preferred treatment strategy in infected necrotizing pancreatitis amongst expert pancreatologists. There is no uniformity regarding the use of FNA and timing of intervention in the first 2-3 weeks of infected necrotizing pancreatitis.

Proactive Versus Standard Percutaneous Catheter Drainage for Infected Necrotizing Pancreatitis

Objectives Percutaneous catheter drainage (PCD) is often the first invasive treatment step for infected necrotizing pancreatitis. A proactive PCD strategy, including frequent and early drain revising and upsizing, may reduce the need for surgical necrosectomy and could improve outcomes, but data are lacking. Methods Necrotizing pancreatitis patients were identified from in-hospital databases (2004–2014). Patients with primary PCD for infected necrotizing pancreatitis were included. Outcomes of patients from 1 center using a proactive PCD strategy were compared with 3 standard strategy centers. Results In total, 369 (25.9%) of 1427 patients received a diagnosis of necrotizing pancreatitis, and 117 (31.7%) of 369 patients underwent primary PCD for infected necrosis: 42 in the proactive group versus 75 in the standard group. Patients in the proactive group had more drain-related procedures (median, 3; interquartile range [IQR], 2–4; versus 2; IQR, 1–2; P < 0.001) and larger final drain sizes (median, 16F; IQR, 14F–20F; versus 14F; IQR, 12F–14F; P < 0.001). Fewer patients underwent additional necrosectomy in the proactive group, 12 (28.6%) versus 39 (52.0%) (adjusted odds ratio, 0.349; 95% confidence interval, 0.137–0.889; P = 0.027), with similar hospital stay and mortality. Conclusions A proactive PCD strategy is associated with reduced need for necrosectomy in infected necrotizing pancreatitis, compared with standard PCD, with similar clinical outcomes.

The Value of a 24/7 Online Nationwide Multidisciplinary Expert Panel for Acute Necrotizing Pancreatitis

Figure 1.Work flow expert panel consultation. 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 Acommon gastrointestinal reason for acute hospitalization. Approximately 20% of patients with acute pancreatitis develop necrotizing pancreatitis. In approximately 30% of these patients, secondary infection of the necrosis occurs, which almost always requires an invasive intervention. Diagnosing infected necrosis on clinical grounds can be difficult. Furthermore, even if infected necrosis is proven, international guidelines advise to postpone invasive intervention to around 4 weeks after disease onset. This allows for necrotic collections to encapsulate (ie, walled-off necrosis), thereby technically facilitating intervention and reducing the risk of complications such as perforation and bleeding. However, the clinical condition of some patients does not permit a delay in intervention. Clinical decision making regarding the indications for and timing of invasive intervention and preferred approach (percutaneous, surgical, or endoscopic) can, therefore, be challenging. Moreover, the incidence of infected necrotizing pancreatitis is low and even tertiary referral centers may only treat 10–15 patients per year. Several international, multidisciplinary, and multicenter approaches have been initiated to improve the care for patients with pancreatitis and facilitate clinical research. In recent years, multiple national study groups have been formed worldwide, for example, in the Netherlands, the United States, Germany, Switzerland, and Hungary. Also evidenceand consensus-based guidelines were composed by international experts in the field. International scientific collaborations were initiated, for example, Pancreas2000