Direct Endoscopic Necrosectomy Significantly Improves Treatment Success in Infected Necrotizing Pancreatitis

Direct endoscopic necrosectomy at index session, as opposed to the step-up approach, for patients with infected necrotizing pancreatitis significantly reduced the number of reinterventions to obtain treatment success as well as decreased the length of hospital stay, according to data presented at Digestive Disease Week (DDW) 2023.¹

Ji Young Bang, MD

Credit: Orlando Health Digestive Health Institute Center

“Endoscopic treatment is the preferred approach for management of infected necrotizing pancreatitis,” wrote Ji Young Bang, MD, Orlando Health Digestive Health Institute Center, and colleagues. “While transluminal stent placement followed by performance of direct endoscopic necrosectomy when there is no clinical improvement is a commonly practiced interventional strategy, the optimal timing to perform endoscopic debridement is unclear.”

In a multicenter, randomized trial, investigators compared outcomes between direct endoscopic necrosectomy and index session and compared it with the step-up approach for patients with infected necrotizing pancreatitis. A total of 70 patients with either confirmed or suspected infected necrotizing pancreatitis who needed intervention between November 2019 and October 2022 were included.

Patients were assigned to groups that either received direct endoscopic necrosectomy at index treatment session after lumen-apposing metal stent placement (n = 37) or received a step-up approach, in which necrosectomy was only conducted if no clinical improvement after stent placement was observed (n = 33). The primary endpoint was the number of reinterventions performed to obtain treatment success, which defined as symptom relief in combination with disease resolution on computed tomography at the 6-month mark.

The mean number of required reinterventions was significantly lower in the patients who received a direct endoscopic necrosectomy at index session (0.9) when compared with patients who received the step-up treatment approach (2.5; P = .001).

Although the overall hospital length stay was significantly shorter in the cohort of patients receiving the direct endoscopic necrosectomy (median 9 days [interquartile range (IQR) 7-20] vs 19 days [IQR 9-33], P = .048), no significant differences in treatment success (94.6% vs 90.9%, P = .66), adverse events (45.9% vs 60.6%, P = .22), mortality (0% vs 6.1%, P = .22), and the mean number of readmissions (.8% vs .8, P = .93) were observed between the direct endoscopic necrosectomy group and step-up treatment group.

References

1. ^{Young Bang J, Lakhtakia S, Thakkar S, Buxbaum J, et al. DIRECT ENDOSCOPIC VERSUS STEP-UP TRANSLUMINAL INTERVENTIONS IN NECROTIZING PANCREATITIS (DESTIN): RESULTS OF A RANDOMIZED TRIAL. Abstract presented at Digestive Disease Week (DDW) 2023 Annual Meeting. Chicago, IL. May 6-10, 2023.}