Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis

被引：143

作者：

Boxhoorn, L. ^{[1
,7
]}

van Dijk, S. M. ^{[2
,7
]}

van Grinsven, J. ^{[2
]}

Verdonk, R. C. ^{[8
]}

Boermeester, M. A. ^{[2
]}

Bollen, T. L. ^{[9
]}

Bouwense, S. A. W. ^{[11
]}

Bruno, M. J. ^{[12
]}

Cappendijk, V. C. ^{[15
]}

Dejong, C. H. C. ^{[11
]}

van Duijvendijk, P. ^{[17
]}

van Eijck, C. H. J. ^{[13
]}

Fockens, P. ^{[1
]}

Francken, M. F. G. ^{[2
]}

van Goor, H. ^{[18
]}

Hadithi, M. ^{[14
]}

Hallensleben, N. D. L. ^{[7
]}

Haveman, J. W. ^{[19
]}

Jacobs, M. A. J. M. ^{[5
]}

Jansen, J. M. ^{[6
]}

Kop, M. P. M. ^{[3
]}

van Lienden, K. P. ^{[3
,9
]}

Manusama, E. R. ^{[20
]}

Mieog, J. S. D. ^{[21
]}

Molenaar, I. Q. ^{[22
]}

Nieuwenhuijs, V. B. ^{[23
]}

Poen, A. C. ^{[24
]}

Poley, J-W ^{[12
]}

van de Poll, M. ^{[11
]}

Quispel, R. ^{[25
]}

Romkens, T. E. H. ^{[16
]}

Schwartz, M. P. ^{[26
]}

Seerden, T. C. ^{[27
]}

Stommel, M. W. J. ^{[18
]}

Straathof, J. W. A. ^{[28
]}

Timmerhuis, H. C. ^{[7
,10
]}

Venneman, N. G. ^{[29
]}

Voermans, R. P. ^{[1
]}

van de Vrie, W. ^{[30
]}

Witteman, B. J. ^{[31
]}

Dijkgraaf, M. G. W. ^{[4
]}

van Santvoort, H. C. ^{[10
,22
]}

Besselink, M. G. ^{[2
]}

机构：

[1] Univ Amsterdam, Amsterdam UMC, Dept Gastroenterol & Hepatol, Amsterdam, Netherlands

[2] Univ Amsterdam, Amsterdam UMC, Dept Surg, Amsterdam, Netherlands

[3] Univ Amsterdam, Amsterdam UMC, Dept Radiol, Amsterdam, Netherlands

[4] Univ Amsterdam, Amsterdam UMC, Dept Epidemiol & Data Sci, Amsterdam, Netherlands

[5] Vrije Univ Amsterdam, Amsterdam UMC, Dept Gastroenterol & Hepatol, Amsterdam Gastroenterol Endocrinol Metab, Amsterdam, Netherlands

[6] Onze Lieve Vrouw Hosp, Dept Gastroenterol & Hepatol, Amsterdam, Netherlands

[7] St Antonius Hosp, Dept Res & Dev, Nieuwegein, Netherlands

[8] St Antonius Hosp, Dept Gastroenterol & Hepatol, Nieuwegein, Netherlands

[9] St Antonius Hosp, Dept Radiol, Nieuwegein, Netherlands

[10] St Antonius Hosp, Dept Surg, Nieuwegein, Netherlands

[11] Maastricht Univ Med Ctr, Dept Surg, Maastricht, Netherlands

[12] Erasmus MC Univ Med Ctr, Dept Gastroenterol & Hepatol, Rotterdam, Netherlands

[13] Erasmus MC Univ Med Ctr, Dept Surg, Rotterdam, Netherlands

[14] Maasstad Hosp, Dept Gastroenterol & Hepatol, Rotterdam, Netherlands

[15] Jerom Bosch Hosp, Dept Radiol, Den Bosch, Netherlands

[16] Jerom Bosch Hosp, Dept Gastroenterol & Hepatol, Den Bosch, Netherlands

[17] Gelre Hosp, Dept Surg, Apeldoorn, Netherlands

[18] Radboud Univ Nijmegen Med Ctr, Dept Surg, Nijmegen, Netherlands

[19] Univ Groningen, Univ Med Ctr Groningen, Dept Surg, Groningen, Netherlands

[20] Med Ctr Leeuwarden, Dept Surg, Leeuwarden, Netherlands

[21] Leiden Univ Med Ctr, Dept Surg, Leiden, Netherlands

[22] Univ Med Ctr Utrecht, Dept Surg, Utrecht, Netherlands

[23] Isala Clin, Dept Surg, Zwolle, Netherlands

[24] Isala Clin, Dept Gastroenterol & Hepatol, Zwolle, Netherlands

[25] Reinier dde Graaf Gasthuis, Dept Gastroenterol & Hepatol, Delft, Netherlands

[26] Meander Med Ctr, Dept Gastroenterol & Hepatol, Amersfoort, Netherlands

[27] Amphia Hosp, Dept Gastroenterol & Flepatol, Breda, Netherlands

[28] Maxima Med Ctr, Dept Gastroenterol & Hepatol, Veldhoven, Netherlands

[29] Med Spectrum Twente, Dept Gastroenterol & Hepatol, Enschede, Netherlands

[30] Albert Schweitzer Hosp, Dept Gastroenterol & Hepatol, Dordrecht, Netherlands

[31] Hosp Gelderse Vallei, Dept Gastroenterol & Hepatol, Ede, Netherlands

来源：

NEW ENGLAND JOURNAL OF MEDICINE | 2021年 / 385卷 / 15期

关键词：

STEP-UP APPROACH; NECROSECTOMY; MANAGEMENT; CLASSIFICATION; NECROSIS; OUTCOMES;

D O I：

10.1056/NEJMoa2100826

中图分类号：

R5 [内科学];

学科分类号：

1002 ; 100201 ;

摘要：

BACKGROUND Infected necrotizing pancreatitis is a potentially lethal disease that is treated with the use of a step-up approach, with catheter drainage often delayed until the infected necrosis is encapsulated. Whether outcomes could be improved by earlier catheter drainage is unknown. METHODS We conducted a multicenter, randomized superiority trial involving patients with infected necrotizing pancreatitis, in which we compared immediate drainage within 24 hours after randomization once infected necrosis was diagnosed with drainage that was postponed until the stage of walled-off necrosis was reached. The primary end point was the score on the Comprehensive Complication Index, which incorporates all complications over the course of 6 months of follow-up. RESULTS A total of 104 patients were randomly assigned to immediate drainage (55 patients) or postponed drainage (49 patients). The mean score on the Comprehensive Complication Index (scores range from 0 to 100, with higher scores indicating more severe complications) was 57 in the immediate-drainage group and 58 in the postponed-drainage group (mean difference, -1; 95% confidence interval [CI], -12 to 10; 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 necrosectomy) was 4.4 in the immediate-drainage group and 2.6 in the postponed-drainage group (mean difference, 1.8; 95% CI, 0.6 to 3.0). In the postponed-drainage group, 19 patients (39%) were treated conservatively with antibiotics and did not require drainage; 17 of these patients survived. The incidence of adverse events was similar in the two groups. CONCLUSIONS This trial did not show the superiority of immediate drainage over postponed drainage with regard to complications in patients with infected necrotizing pancreatitis. Patients randomly assigned to the postponed-drainage strategy received fewer invasive interventions.

引用

页码：1372 / 1381

页数：10

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