Postponed Catheter Drainage for Infected Necrotizing Pancreatitis Associated With Decreased Rates of Invasive Interventions

Treatment approach of infected necrotizing pancreatitis with postponed catheter drainage is associated with fewer invasive interventions than with immediate drainage. These findings, from a multicenter, randomized superiority trial, were published in The New England Journal of Medicine.

The Postponed or Immediate Drainage of Infected Necrotizing Pancreatitis (POINTER) trial included patients (N=104) who developed infected necrotizing pancreatitis within 35 days of the onset of acute pancreatitis symptoms. Patients were recruited from 22 centers in the Netherlands between 2015 and 2019. Participants were randomly assigned in a 1:1 ratio to receive immediate (n=55) or postponed (n=49) catheter drainage.

Immediate drainage occurred within 24 hours of infection diagnosis and delayed drainage occurred once walled-off necrosis was reached. Patients were assessed by the Comprehensive Complication Index (CCI) up to 6 months.

The immediate and postponed cohorts consisted of patients aged mean 60±14 and 59±11 years, 58% and 65% were men, pancreatitis was caused by gallstones among 65% and 59% of patients, 64% and 67% of patients had <30% necrosis, and the average time from symptom onset to diagnosis was 8±8 and 9±7 days, respectively.

The mean CCI scores were 57 among the immediate and 58 among the postponed drainage groups (mean difference, -1; 95% CI, -12 to 10 points; P =.90).

No significant differences between groups for mortality (relative risk [RR], 1.25; 95% CI, 0.42-3.68) or the major complications of new-onset organ failure (RR, 1.13; 95% CI, 0.57-2.26), bleeding (RR, 0.71; 95% CI, 0.31-1.66), perforation of a visceral organ and/or enterocutaneous fistula (RR, 1.11; 95% CI, 0.32-3.91), and pancreaticocutaneous fistula (RR, 1.34; 95% CI, 0.40-4.46) were observed.

The immediate drainage recipients had higher rates of surgical, endoscopic, and radiological interventions (mean difference, 1.8; 95% CI, 0.6-3.0). Necrosectomy was required by 51% of the immediate and 22% of the postponed drainage cohorts.

The average length of stay was numerically less among the postponed drainage group, but these differences failed to reach significance (51 vs 59 days). The total inpatient care costs were similar between groups (mean difference, $7845; 95% CI, -$16,499 to -$29,721).

This study may have been limited by use of the CCI score as the primary endpoint, as this score was designed to assess postoperative complications; however, the study authors felt no other tool available assessed the outcomes of interest.

These data indicated that patients with infected necrotizing pancreatitis who received postponed drainage at the point of walled-off necrosis received fewer invasive interventions than patients who received drainage within 24 hours of diagnosis.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

Reference

Boxhoorn L, van Dijk SM, van Grinsven J, et al. Immediate versus postponed intervention for infected necrotizing pancreatitis. N Engl J Med. 2021;385(15):1372-1381. doi:10.1056/NEJMoa2100826