One discussion this week included the question of step-up approach versus open necrosectomy for pancreatitis.
BACKGROUND: The 2010 randomized PANTER trial in (infected) necrotizing pancreatitis found a minimally invasive step-up approach to be superior to primary open necrosectomy for the primary combined endpoint of mortality and major complications, but long-term results are unknown.
NEW FINDINGS: With extended follow-up, in the step-up group, patients had fewer incisional hernias, less exocrine insufficiency and a trend towards less endocrine insufficiency. No differences between groups were seen for recurrent or chronic pancreatitis, pancreatic endoscopic or surgical interventions, quality of life or costs.
IMPACT: Considering both short and long-term results, the step-up approach is superior to open necrosectomy for the treatment of infected necrotizing pancreatitis.
Hollemans et al conclude:
“Some advocate that a down-side of a minimally invasive step-up approach is that patients need additional invasive interventions during follow-up because of persisting collections or necrosis and that for this reason a primary open necrosectomy is a more definitive initial treatment. Results of our current study refute this assumption and further accentuate the benefits of a minimally invasive step-up approach during follow-up. It should be acknowledged, however, that necrotizing pancreatitis is a very heterogeneous disease. Different invasive treatment strategies therefore need to be considered in each individual patient, without ruling out the option of open necrosectomy. Nevertheless, following from the results of our longstanding experience in nationwide research on treatment of necrotizing pancreatitis, we feel confident to emphasize the longterm superiority of the minimally invasive step-up approach over primary open necrosectomy in the treatment of infected necrotizing pancreatitis” (p.1025).
References: Hollemans RA, et al. Superiority of step-up approach vs open necrosectomy in long-term follow-up of patients with necrotizing pancreatitis. Gastroenterology. 2019 Mar;156(4):1016-1026. doi: 10.1053/j.gastro.2018.10.045.
van Santvoort HC, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. NEJM. 2010 Apr 22;362:1491-1502. doi: 10.1056/NEJMoa0908821. (Current Controlled Trials number, ISRCTN13975868.)