Immediate drainage of infected necrotizing pancreatitis, within 24 hours of diagnosis, was not superior to delayed drainage, suggests a new study from the Netherlands, published in the New England Journal of Medicine.¹

One hundred and four patients with infected necrotizing pancreatitis were recruited in the multicenter, randomized POINTER (Postponed or Immediate Drainage of Infected Necrotizing Pancreatitis) trial. Of these, 55 patients underwent immediate catheter drainage (endoscopic transluminal drainage or image-guided percutaneous drainage) after diagnosis, while in 49 patients drainage was delayed until the necrosis became encapsulated. The  Comprehensive Complication Index (CCI) score over 6 months of follow-up was the primary end point. The scores range from 0 (no complication) to 100 (death); higher scores are indicative of more severe complications. 

At 6 months, the mean scores on the CCI were comparable between the two groups – 57 in the immediate-drainage group and 58 in the postponed-drainage group. Nineteen (39%) patients in the latter group did not require drainage at all and could be managed with antibiotics; of these, 17 patients survived. Patients in the postponed-drainage group also required fewer invasive interventions than patients in the immediate-drainage group (mean 2.6 vs 4.4, respectively).

The incidence of major complications did not differ between the two groups. Mortality rate also did not differ significantly: 13% in the immediate-drainage group and 10% in the postponed-drainage group (relative risk, 1.25; 95% CI, 0.42 to 3.68).

The 2019 American Gastroenterological Association Clinical Practice Guidelines recommend percutaneous drainage as well as transmural endoscopic drainage as first-line nonsurgical approaches for patients with walled-off pancreatic necrosis. Percutaneous drainage should be considered in those with infected or symptomatic necrotic collections in the early acute period (<2 weeks) and in those with walled-off necrosis who are too ill to undergo endoscopic or surgical intervention.²

This study has shown no significant difference in the outcome between immediate- and delayed-drainage approach for the management of infected necrotizing pancreatitis. It further suggests that “an initial conservative approach with antibiotics is justified when infected necrosis is diagnosed”. Drainage can be delayed in clinically stable patients until the development of walled-off necrosis.

References

1. Boxhoorn L, et al for the Dutch Pancreatitis Study Group. Immediate versus postponed intervention for infected necrotizing pancreatitis. N Engl J Med. 2021 Oct 7;385:1372-1381.
2. Baron TH, et al. American Gastroenterological Association Clinical Practice Update: management of pancreatic necrosis. Gastroenterology. 2020 Jan;158(1):67-75.e1.