Immediate catheter drainage not superior to delayed in infected necrotizing pancreatitis
A trial found that catheter drainage within 24 hours was associated with similar complications but a greater number of interventions compared to drainage that was delayed until the development of walled-off necrosis.
Earlier catheter drainage in patients with infected necrotizing pancreatitis was not superior to delayed drainage in a recent trial.
The POINTER (Postponed or Immediate Drainage of Infected Necrotizing Pancreatitis) trial tested the hypothesis that a minimally invasive step-up approach with earlier catheter drainage would be superior to delaying drainage until the infected necrosis is encapsulated. The trial protocol allowed for both endoscopic and surgical step-up approaches. Researchers randomly assigned 104 patients with infected necrotizing pancreatitis at 22 centers to receive antibiotics and immediate drainage within 24 hours after randomization (n=55) or to receive antibiotics and drainage that was postponed until the development of walled-off necrosis (n=49). Participants' onset of acute pancreatitis was within 35 days before randomization. The primary end point was the score on the Comprehensive Complication Index, which incorporates all complications during six months of follow-up and has a range of scores from 0 to 100, with higher scores indicating more severe complications. Results were published online Oct. 7 by the New England Journal of Medicine.
The mean score on the Comprehensive Complication Index was 57 in the immediate-drainage group and 58 in the postponed-drainage group (P=0.90). Mortality was 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 mean number of interventions (catheter drainage and surgical necrosectomy) was 4.4 in the immediate-drainage group and 2.6 in the postponed-draining group, with 51% in the former group and 22% in the latter group receiving necrosectomy. Nineteen patients (39%) were treated conservatively with antibiotics and did not require drainage; 17 of these patients survived. The incidence of adverse events was similar between the two groups.
Limitations of the trial include its small sample size. A larger trial may have identified significant differences in Comprehensive Complication Index scores between the groups, the study authors noted. “Our results do not support the hypothesis that catheter drainage performed immediately after diagnosis of infected necrosis leads to better patient outcomes with fewer complications than postponed drainage,” they wrote, adding that the findings differ from those of previous retrospective studies.
The management of acute necrotizing pancreatitis is now mainly nonsurgical, and these results add to the growing volume of high-quality studies guiding evidence-based recommendations, an accompanying editorial said. “As shown in the present study, nonoperative drainage in clinically stable patients is best delayed until the development of walled-off necrosis, which usually occurs 30 or more days after the onset of pancreatitis,” the editorialist wrote.