Endoscopic Versus Surgical Step-Up Approach for Infected Necrotizing Pancreatitis (ExTENSION): Long-term Follow-up of a Randomized Trial

Endoscopic Treatment of Complex Walled-Off Necrosis in Necrotizing Pancreatitis With Two Simultaneous Lumen-Apposing Metal Stents: A Case Report

“…The analysis demonstrated no difference in mortality, although the endoscopic approach had fewer pancreatic fistula, enterocutaneous fistula, perforation, and multiple organ dysfunction after the intervention with statistical significance [ 14 ]. Furthermore, it was realized in a trial in the Netherlands that performed a long-term follow-up of seven years after endoscopic and surgical step-up approach demonstrates there is no superiority in reducing death or major complications in any group, although, after the initial six months, there were fewer pancreaticocutanous fistulas and reinterventions in the endoscopic group [ 15 ].…”

Navigating the Stormy Sea of Infected Necrotizing Pancreatitis: Are We There Yet? Well Almost!

“…Whether the third variable, namely, the type of initial intervention for INP affects the outcomes, is the focus of the current study. 7 The TENSION trial had shown that both the modalities were similar in terms of primary outcomes till 6 months of follow-up, except for a higher proportion of pancreatic fistula in 25.5% of patients treated with a percutaneous minimally invasive surgical approach. The authors have now followed these patients for a median of 7 years and shown that both the modalities were similar for the primary composite outcome, except for fewer percutaneous pancreatic fistula in the endoscopy group (8% vs 34%; relative risk, 0.23; 95% confidence interval, 0.08-0.83) requiring fewer reinterventions in the endoscopy arm (7% vs 24%; relative risk, 0.29; 95% confidence interval, 0.09-0.99).…”

“…5,6 In this issue of Gastroenterology, the Dutch Pancreatitis Study Group has reported on the long-term outcomes of patients with INP treated either by an endoscopic step-up or minimally invasive surgical approach as the extension of their TENSION trial. 7 Significant medium-and long-term outcomes after recovery from AP include a propensity to develop recurrent acute and even chronic pancreatitis, recurrence of peripancreatic fluid collections, pancreatic fistula, and functional consequences with endocrine and exocrine insufficiency. Conceptually, such outcomes may be determined by 3 factors:…”

“…10 Patients with genetic polymorphisms/mutations in any of the pancreatitis associated genes such as PRSS1, SPINK1, and CFTR are at risk of RAP and often chronic pancreatitis. 11 In the Dutch study, 7 23 patients (28%) developed RAP owing to alcohol (n ¼ 2), gallstones (n ¼ 8), idiopathic (n ¼ 10), endoscopic retrograde cholangiopancreatography (n ¼ 1), pancreatic injury (n ¼ 1), and unknown (n ¼ 1) cause. The idiopathic etiology of AP, seen in 43% of patients with RAP, needs further study, but it is quite likely that such patients might have an underlying genetic polymorphism/mutation.…”

LAMS versus plastic stents for infected pancreatic walled off necrosis (WON): has the addition of the TENSION trial to the AXIOMA study eased the tension?

“…Transpapillary drainage is provided therapeutically by ERCP. All patients from the TENSION trial were subjected to ERCP 5. However, in the AXIOMA study, failure to perform ERCP could have resulted in an altered primary endpoint outcome.…”