Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis

Boxhoorn, Lotte; Dijk, Sven M. van; Grinsven, Janneke van; Verdonk, Robert C.; Boermeester, Marja A.; Bollen, Thomas L.; Bouwense, Stefan; Bruno, Marco J.; Cappendijk, Vincent C.; Dejong, Cornelis H. C.; Duijvendijk, Peter van; Eijck, Casper H.J. van; Fockens, Paul; Francken, Michiel F.G.; Goor, Harry van; Hadithi, Muhammed; Hallensleben, Nora D L; Haveman, Jan Willem; Jacobs, Maarten; Jansen, Jeroen M.; Kop, Marnix P. M.; Lienden, Krijn P. van; Manusama, Eric R.; Mieog, J. Sven D.; Molenaar, I. Quintus; Nieuwenhuijs, Vincent B.; Poen, Alexander C.; Poley, Jan–Werner; Poll, Marcel van de; Quispel, Rutger; Römkens, Tessa E H; Schwartz, Matthijs P.; Seerden, Tom; Stommel, Martijn W J; Straathof, Jan Willem; Timmerhuis, Hester C.; Venneman, Niels G.; Voermans, Rogier P.; Vrie, Wim van de; Witteman, Ben J.M.; Dijkgraaf, Marcel G. W.; Santvoort, Hjalmar C. van; Besselink, Marc G.

doi:10.1056/nejmoa2100826

Cited by 149 publications

(145 citation statements)

References 27 publications

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“…In addition, only 18.37% of patients with ANP showed improvement after PCD intervention. This is lower than the 35–51% reported by other research institutes ( 3 , 7 , 9 , 16 , 17 ). It may be that our hospital is one of the largest acute pancreatitis diagnosis and treatment centers in northern China.…”

Section: Discussioncontrasting

confidence: 61%

“…Although the comprehensive complication index score and mortality of the two groups were similar, it did not prove the superiority of early intervention in the treatment of patients with IPN. It is only suggested that early PCD intervention can be considered for IPN patients with rapid clinical deterioration ( 7 ). In this study, patients in the early group received PCD intervention after the failure of conservative antibiotic treatment.…”

Section: Discussionmentioning

confidence: 99%

“…In a recent international survey on the diagnosis and intervention time of IPN for patients diagnosed with IPN, although 55% of pancreatic experts supported antibiotic treatment first and puncture treatment after necrosis wrapping, but 45% of pancreatic experts still believe that minimally invasive intervention should be performed immediately after the diagnosis of IPN ( 6 ). Recently, a multicenter Randomized Controlled Trial (RCT) study published by the Dutch pancreatitis study group found that although early intervention did not benefit IPN patients more than delayed intervention, early intervention was an effective treatment option for IPN patients with clinical deterioration, but there was no clear indication of patients suitable for early intervention ( 7 ).…”

Section: Introductionmentioning

confidence: 99%

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How to Identify the Indications for Early Intervention in Acute Necrotizing Pancreatitis Patients: A Long-Term Follow-Up Study

Cao

Zheng

et al. 2022

Front. Surg.

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AimTo explore the indications for early intervention in patients with acute necrotizing pancreatitis (ANP) and evaluate the effect of early intervention on the prognosis of ANP patients.MethodsThe clinical data of patients with ANP who underwent general surgery at Xuanwu Hospital of Capital Medical University from January 1, 2014, to December 31, 2020, were collected retrospectively. The patients were followed-up every 6 months after discharge, and the last follow-up date was June 30, 2021.ResultsA total of 98 patients with ANP were included in the study. They were divided into an early group (n= 43) and a delayed group (n = 55) according to the first percutaneous drainage (PCD) intervention time (≤ 4 weeks or > 4 weeks). Body temperature, inflammatory factor levels, and the number of patients with persistent organ failure (POF) were higher in the early group than in the delayed group. After the minimally invasive intervention, the body temperature and inflammatory factors of the two groups decreased significantly, most patients with POF improved, and the number of patients with reversal of POF in the early group was higher than that in the delayed group. Although the patients in the early group required more surgical intervention than those in the delayed group, there was no significant difference in mortality, incidence of postoperative complications, total length of hospital stay, or operation cost between the two groups. During long-term follow-up, there was no significant difference in the incidence of short-term and long-term complications and overall survival between the two groups.ConclusionsCompared to patients in the delayed group, early intervention did not affect the prognosis of patients with ANP. It may be more suitable for patients with ANP with deterioration [such as POF or infected pancreatic necrosis (IPN)].

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Section: Discussioncontrasting

confidence: 61%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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How to Identify the Indications for Early Intervention in Acute Necrotizing Pancreatitis Patients: A Long-Term Follow-Up Study

Cao

Zheng

et al. 2022

Front. Surg.

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“…Studies on delay in surgical source control were mostly conducted among patients with single disease entities such as necrotizing fasciitis, peptic ulcer perforation, cholangitis, infected pancreatic necrosis or urinary tract infections and mostly had small samples with heterogeneous disease severity [ 2 , 10 – 12 , 32 – 34 ]. Two recent large studies among patients with sepsis [ 13 ] and septic shock [ 14 ] did not find a significant increase in mortality by delayed source control.…”

Section: Discussionmentioning

confidence: 99%

Adverse effects of delayed antimicrobial treatment and surgical source control in adults with sepsis: results of a planned secondary analysis of a cluster-randomized controlled trial

et al. 2022

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Background Timely antimicrobial treatment and source control are strongly recommended by sepsis guidelines, however, their impact on clinical outcomes is uncertain. Methods We performed a planned secondary analysis of a cluster-randomized trial conducted from July 2011 to May 2015 including forty German hospitals. All adult patients with sepsis treated in the participating ICUs were included. Primary exposures were timing of antimicrobial therapy and delay of surgical source control during the first 48 h after sepsis onset. Primary endpoint was 28-day mortality. Mixed models were used to investigate the effects of timing while adjusting for confounders. The linearity of the effect was investigated by fractional polynomials and by categorizing of timing. Results Analyses were based on 4792 patients receiving antimicrobial treatment and 1595 patients undergoing surgical source control. Fractional polynomial analysis identified a linear effect of timing of antimicrobials on 28-day mortality, which increased by 0.42% per hour delay (OR with 95% CI 1.019 [1.01, 1.028], p ≤ 0.001). This effect was significant in patients with and without shock (OR = 1.018 [1.008, 1.029] and 1.026 [1.01, 1.043], respectively). Using a categorized timing variable, there were no significant differences comparing treatment within 1 h versus 1–3 h, or 1 h versus 3–6 h. Delays of more than 6 h significantly increased mortality (OR = 1.41 [1.17, 1.69]). Delay in antimicrobials also increased risk of progression from severe sepsis to septic shock (OR per hour: 1.051 [1.022, 1.081], p ≤ 0.001). Time to surgical source control was significantly associated with decreased odds of successful source control (OR = 0.982 [0.971, 0.994], p = 0.003) and increased odds of death (OR = 1.011 [1.001, 1.021]; p = 0.03) in unadjusted analysis, but not when adjusted for confounders (OR = 0.991 [0.978, 1.005] and OR = 1.008 [0.997, 1.02], respectively). Only, among patients with septic shock delay of source control was significantly related to risk-of death (adjusted OR = 1.013 [1.001, 1.026], p = 0.04). Conclusions Our findings suggest that management of sepsis is time critical both for antimicrobial therapy and source control. Also patients, who are not yet in septic shock, profit from early anti-infective treatment since it can prevent further deterioration. Trial registration ClinicalTrials.gov (NCT01187134). Registered 23 August 2010, NCT01187134

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“…Die Dringlichkeit der Therapie und somit auch der Druck zur Intervention richtet sich also nach dem klinischen Zustand. Liegt eine mutmaßlich infizierte Pankreasnekrose vor, so sollte zunächst mit einem Breitbandantibiotikum behandelt werden und eine Intervention im Step-up Approach nur bei fehlender klinischer Besserung erfolgen [15]. Vor jeder geplanten Intervention ist eine Schnittbildgebung mit Kontrastmittel obligat.…”

Section: Caveunclassified