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• W2912887184 abstract "See “An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis,” by Bang JY, Arnoletti JP, Holt BA, et al, on page 1027; and “Superiority of step-up approach vs open necrosectomy in long-term follow-up of patients with necrotizing pancreatitis, by Hollemans RA, Bakker OJ, Boermeester MA, et al, on page 1016. See “An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis,” by Bang JY, Arnoletti JP, Holt BA, et al, on page 1027; and “Superiority of step-up approach vs open necrosectomy in long-term follow-up of patients with necrotizing pancreatitis, by Hollemans RA, Bakker OJ, Boermeester MA, et al, on page 1016. Necrotizing pancreatitis occurs in ≤10%–20% of all patients with acute pancreatitis and portends a severe course of the disease.1Garg P.K. Madan K. Pande G.K. et al.Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis.Clin Gastroenterol Hepatol. 2005; 3: 159-166Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar Pancreatic and peripancreatic necroses may strike a dual blow: (1) by causing sterile systemic inflammatory response syndrome and (2) by providing a fertile ground for microorganisms, resulting in infected necrosis and sepsis.1Garg P.K. Madan K. Pande G.K. et al.Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis.Clin Gastroenterol Hepatol. 2005; 3: 159-166Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar Sterile systemic inflammatory response syndrome is due to the release of damage-associated molecular patterns from necrotic cells that lead to immune activation and release of cytokines.2Singh P. Garg P.K. Pathophysiological mechanisms in acute pancreatitis: Current understanding.Indian J Gastroenterol. 2016; 35: 153-166Crossref PubMed Scopus (59) Google Scholar Systemic inflammation, when severe, may lead to organ failure, which is the cause of most mortality in patients with acute pancreatitis. Infection of necrotic fluid collections is an ominous development during the course of necrotizing pancreatitis, and is an independent determinant of survival. Infection may develop any time during the disease process, but mostly occurs beyond the second week of illness.1Garg P.K. Madan K. Pande G.K. et al.Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis.Clin Gastroenterol Hepatol. 2005; 3: 159-166Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar The revised Atlanta classification defines necrotic collections of <4 weeks duration as acute necrotic collections.3Banks P.A. Bollen T.L. Dervenis C. et al.Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus.Gut. 2013; 62: 102-111Crossref PubMed Scopus (3523) Google Scholar As part of the body’s reparative processes, the necrotic areas gradually become localized and walled off, known as “walled off necrosis.” The distinction between acute necrotic collections and walled off necrosis has major implications for the treatment of patients with infected necrosis. There is a correlation between the extent and infection of necrosis, and organ failure, which may either precede (mostly) or follow infected necrosis.4Padhan R. Jain S. Agarwal S. et al.Primary and secondary organ failures cause mortality differentially in acute pancreatitis and should be distinguished.Pancreas. 2018; 47: 302-307Crossref PubMed Scopus (25) Google Scholar The outcome of patients with infected necrosis is worse in those with than in those without organ failure.5Schepers N.J. Bakker O.J. Besselink M.G. et al.Impact of characteristics of organ failure and infected necrosis on mortality in necrotising pancreatitis.Gut. 2018; ([Epub ahead of print].)https://doi.org/10.1136/gutjnl-2017-314657Crossref Scopus (139) Google Scholar In the past, interventions for acute necrotizing pancreatitis were the domain of open surgery,6Connor S. Raraty M.G. Neoptolemos J.P. et al.Does infected pancreatic necrosis require immediate or emergency debridement?.Pancreas. 2006; 33: 128-134Crossref PubMed Scopus (33) Google Scholar which was eventually abandoned for sterile necrosis after Bradley and Allen7Bradley III, E.L. Allen K. A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis.Am J Surg. 1991; 16: 19-24Abstract Full Text PDF Scopus (394) Google Scholar showed in a seminal paper that outcomes of patients treated nonoperatively were better. Infected necrosis was still thought to mandate open surgery, until it was reported that many patients with infected necrosis could be treated without surgery by catheter drainage and antibiotics with similar results.8Garg P.K. Sharma M. Madan K. et al.Primary conservative treatment results in mortality comparable to surgery in patients with infected pancreatic necrosis.Clin Gastroenterol Hepatol. 2010; 8: 1089-1094Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar Then, the landmark Dutch multicenter, randomized PANTER trial showed that step-up therapy from percutaneous catheter drainage to minimally invasive surgery as required, done through video-assisted retroperitoneal debridement (VARD), was as effective as open surgery, but with less organ failure, hernia, diabetes, and other complications.9van Santvoort H.C. Besselink M.G. Bakker O.J. et al.A step-up approach or open necrosectomy for necrotizing pancreatitis.N Engl J Med. 2010; 362: 1491-1502Crossref PubMed Scopus (996) Google Scholar An important observation in that study was that one-third of patients recovered with antibiotics and percutaneous catheter drainage without a need for necrosectomy. It also established that minimally invasive necrosectomy is the preferred option in patients with appropriate anatomy who required intervention. This observation has subsequently been validated.10Horvath K. Freeney P. Escallon J. et al.Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study.Arch Surg. 2010; 145: 817-825Crossref PubMed Scopus (152) Google Scholar Simultaneous developments in endoscopic transluminal therapy of pseudocysts and necrotic collections paved the way for a natural orifice approach to necrosectomy, including for infected necrosis.11Freeman M.L. Werner J. vanSantvoort H.C. et al.Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference.Pancreas. 2012; 41: 1176-1194Crossref PubMed Scopus (282) Google Scholar, 12Trikudanathan G. Attam R. Arain M.A. et al.Endoscopic interventions for necrotizing pancreatitis.Am J Gastroenterol. 2014; 109: 969-981Crossref PubMed Scopus (49) Google Scholar Endoscopic cystogastrostomy has previously been shown to have equal efficacy, but with shorter hospital stay, better physical and mental health of patients, and lower cost than open surgical cystgastrostomy for drainage of pseudocysts.13Varadarajulu S. Bang J.Y. Sutton B.S. et al.Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial.Gastroenterology. 2013; 145: 583-590.e1Abstract Full Text Full Text PDF PubMed Scopus (298) Google Scholar Among the various minimally invasive surgical techniques, laparoscopy has also been used for necrosectomy, but with limited applications.11Freeman M.L. Werner J. vanSantvoort H.C. et al.Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference.Pancreas. 2012; 41: 1176-1194Crossref PubMed Scopus (282) Google Scholar, 14Driedger M. Zyromski N.J. Visser B.C. et al.Surgical Transgastric necrosectomy for necrotizing pancreatitis: a single-stage procedure for walled-off pancreatic necrosis.Ann Surg. 2018 Sept 13; ([Epub ahead of print] PMID: 30216220)Crossref PubMed Scopus (32) Google Scholar Multiple case series have suggested the efficacy of endoscopic transluminal drainage and necrosectomy for necrotic collections.11Freeman M.L. Werner J. vanSantvoort H.C. et al.Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference.Pancreas. 2012; 41: 1176-1194Crossref PubMed Scopus (282) Google Scholar, 12Trikudanathan G. Attam R. Arain M.A. et al.Endoscopic interventions for necrotizing pancreatitis.Am J Gastroenterol. 2014; 109: 969-981Crossref PubMed Scopus (49) Google Scholar However, endoscopic necrosectomy had not been compared with minimally invasive surgery until recently. Two studies on the evolving treatment of infected necrosis published in the current issue of Gastroenterology add substantially to our knowledge regarding this challenging problem. The MISER trial by Bang et al15Bang J.Y. Arnoletti J.P. Holt B.A. et al.An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis.Gastroenterology. 2019; 156: 1027-1040Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar prospectively compared endoscopic transluminal drainage and necrosectomy with minimally invasive surgery; the study by Hollemans et al16Hollemans R.A. Bakker O.J. Boermeester M.A. et al.Superiority of step-up approach vs open necrosectomy in long-term follow-up of patients with necrotizing pancreatitis.Gastroenterology. 2019; 156: 1016-1026Abstract Full Text Full Text PDF Scopus (98) Google Scholar analyzed long term outcomes of patients previously randomized to minimally invasive step-up therapy (VARD) compared with open surgery in the PANTER trial. In the trial by Bang et al, the composite primary outcome (new-onset organ failure, enteral or pancreatic-cutaneous fistula, bleeding, perforation of visceral organ, or death during a 6-month follow-up) was significantly less frequent in the endoscopy group compared with the minimally invasive surgery group (11.8% vs 40.6%; risk ratio, 0.29; P = .007) in patients with suspected/proven infected necrosis. As in most individual randomized trials comparing treatment strategies, there was no significant difference in all-cause mortality (8.8% vs 6.3%; P = .9). However, costs were lower and quality-of-life scores were better in the endoscopy group. VARD, by definition, will create at least a temporary externally drained pancreatic fistula and if one does not include fistula rate (0% and 28%) in the composite outcome, the 2 treatments were similar. The minimally invasive surgery group included both laparoscopic cystogastrostomy with necrosectomy in majority, and VARD in some patients. The choice was at the discretion of the surgeon and tailored to the individual patient, which might be considered a more pragmatic approach, although at the cost of heterogeneity in the surgical group. The approach in the endoscopic group was also heterogenous, with multiple transluminal gateways in the majority of patients, and the use of multiple plastic stents in some patients and metal stents in others. Such a tailored approach both in the endoscopy and surgical groups may make the results generalizable to a wider group of patients than a strictly regimented approach. Fistulae may result in substantial morbidity, and often require prolonged hospitalization and intervention, and thus merit inclusion as a major end point. Fistulae, observed exclusively in the surgical group, were likely a consequence of external drainage and intervention, whether percutaneous or minimally invasive surgical. The results of the MISER trial can be compared with another recently published randomized trial comparing endoscopic transluminal therapy with minimally invasive surgery, the TENSION trial.17Van Brunschot S. van Grinsven J. van Santvoort H.C. et al.Endoscopic or surgical step-up approach for infected necrotizing pancreatitis: a multicenter randomized trial.Lancet. 2018; 391: 51-58Abstract Full Text Full Text PDF PubMed Scopus (326) Google Scholar Important differences between these studies, which may influence decisions about best practice, are summarized in Table 1. The most important difference is that the MISER study included fistulae in the major composite end point, whereas the Dutch study did not, in large part explaining the disparity in conclusions. The MISER Trial showed that the endoscopic approach was superior and the Dutch study concluded that the endoscopic approach and minimally invasive step-up were similar. In addition, the Dutch study included relatively stable patients at a median of 6 weeks after the onset of illness with 70% having walled off necrosis and 30% partially walled off necrosis. The mean SOFA score, a measure of organ failure, was 0 or 1, suggesting stable patients. In the MISER trial also, patients had walled off necrosis, even though the mean time to intervention was 4 weeks, so that a significant number of patients underwent intervention before that interval. Inclusion of a high proportion of patients in American Society of Anaesthesiologists classes 3 and 4, and 29% patients with organ failure is a strength of the MISER trial, which lends support to the concept that the endoscopic approach could be effective even in sick patients. The mortality in the MISER trial was quite low at 8% despite the inclusion of very ill patients. This admirably low mortality may be due to early aggressive treatment, or a different patient profile. Although the primary determinant of mortality in infected necrosis is persistent organ failure,4Padhan R. Jain S. Agarwal S. et al.Primary and secondary organ failures cause mortality differentially in acute pancreatitis and should be distinguished.Pancreas. 2018; 47: 302-307Crossref PubMed Scopus (25) Google Scholar, 5Schepers N.J. Bakker O.J. Besselink M.G. et al.Impact of characteristics of organ failure and infected necrosis on mortality in necrotising pancreatitis.Gut. 2018; ([Epub ahead of print].)https://doi.org/10.1136/gutjnl-2017-314657Crossref Scopus (139) Google Scholar a pooled and risk-adjusted analysis has suggested that endoscopic and minimally invasive surgical approaches may be independently associated with lower mortality than open surgery.18van Brunschot S. Hollemans R.A. et al.Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients.Gut. 2018; 67: 697-706PubMed Google Scholar The advent of minimally invasive techniques coupled with intensive care should enable us to strive for single digit mortality in patients with infected necrosis.Table 1Summary of 2 Recent Randomized, Controlled Trials Comparing Endoscopic and Minimally Invasive Surgical Step-Up Approach for Suspected/Proven Infected NecrosisTENSION TrialMISER TrialEndoscopicSurgicalEndoscopicSurgicalNo. of patients51473432Percent infected necrosis23 (45%)27 (57%)31 (91%)30 (94%)Outcomes Composite end point22 (43%)21 (45%)4(12%)13(41%) New-onset organ failureSingle7 (14%)13 (28%)NRNRMultiple2 (4%)6 (13%)2 (6%)3 (9%) Death9 (18%)6 (13%)3 (9%)2 (6%)Complications Bleeding11 (22%)10 (21%)03 (9%) Perforation4 (8%)8 (17%)00 Fistula (pancreatic)2/42 (5%)13/42 (32%)09 (28%)NR, not recorded. Open table in a new tab NR, not recorded. Another issue that needs to be considered is the timing of intervention in patients with suspected infected necrosis. Open surgical necrosectomy has been shown in a randomized, controlled trial to have a worse outcome if performed before 4 weeks.19Meier J. Leon E.L. Castillo A. et al.Early versus late necrosectomy in severe necrotizing pancreatitis.Am J Surg. 1997; 173: 71-75Abstract Full Text PDF PubMed Scopus (417) Google Scholar The same cut-off is generally recommended for percutaneous catheter and endoscopic transluminal drainage. However, a recent study has shown that early endoscopically centered intervention (<4 weeks) in the face of clinical deterioration with organ failure provided acceptable results without any difference in complications, compared with standard intervention after 4 weeks.20Trikudanathan G. Tawfik P. Amateau S.K. et al.Early (<4 weeks) versus standard (≥ 4 weeks) endoscopically centered step-up interventions for necrotizing pancreatitis.Am J Gastroenterol. 2018; 113: 1550-1558Crossref PubMed Scopus (68) Google Scholar Of the 193 patients who required intervention in that study, 76 underwent early and 117 standard intervention. As compared with standard intervention, early intervention was more often performed for infected necrosis with deteriorating organ failure, which improved dramatically after intervention in both groups. Early endoscopic intervention was performed in a substantial number of patients without encapsulation of the collection. There was significantly higher mortality (13% vs 4%; P = .02) and need for rescue open necrosectomy (7% vs 1%; P = .03) in the early intervention group, which were attributed to sicker patients, and more refractory and extensive collections, but were not the result of complications of endoscopic or percutaneous catheter intervention. It has been suggested that acute necrotic collections may wall off within 3 weeks in up to 43% of patients.21van Grinsven J. van Brunschot S. van Baal M.C. et al.Natural history of gas configurations and encapsulation in necrotic collections during necrotizing pancreatitis.J Gastrointest Surg. 2018; 22: 1557-1564Crossref PubMed Scopus (30) Google Scholar Thus, it remains unclear at what stage patients with infected necrosis and clinical deterioration should undergo percutaneous catheter drainage, endoscopic transluminal drainage, or both, and not be stalled further with medical management. An additional issue in relation to infected necrosis is the need for necrosectomy in patients who show improvement after drainage. Overall one third to half of patients in the 2 randomized, controlled trials recovered with either percutaneous or endoscopic drainage alone,9van Santvoort H.C. Besselink M.G. Bakker O.J. et al.A step-up approach or open necrosectomy for necrotizing pancreatitis.N Engl J Med. 2010; 362: 1491-1502Crossref PubMed Scopus (996) Google Scholar, 17Van Brunschot S. van Grinsven J. van Santvoort H.C. et al.Endoscopic or surgical step-up approach for infected necrotizing pancreatitis: a multicenter randomized trial.Lancet. 2018; 391: 51-58Abstract Full Text Full Text PDF PubMed Scopus (326) Google Scholar although this fraction is substantially lower in other series, in which ≤80% of patients fail aggressive dual modality drainage alone and require endoscopic or other means of necrosectomy.11Freeman M.L. Werner J. vanSantvoort H.C. et al.Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference.Pancreas. 2012; 41: 1176-1194Crossref PubMed Scopus (282) Google Scholar, 12Trikudanathan G. Attam R. Arain M.A. et al.Endoscopic interventions for necrotizing pancreatitis.Am J Gastroenterol. 2014; 109: 969-981Crossref PubMed Scopus (49) Google Scholar, 19Meier J. Leon E.L. Castillo A. et al.Early versus late necrosectomy in severe necrotizing pancreatitis.Am J Surg. 1997; 173: 71-75Abstract Full Text PDF PubMed Scopus (417) Google Scholar Large areas of necrosis, poor liquefaction, diffuse and multifocal collections, and the presence of organ failure are some of the important factors that govern response to drainage alone.9van Santvoort H.C. Besselink M.G. Bakker O.J. et al.A step-up approach or open necrosectomy for necrotizing pancreatitis.N Engl J Med. 2010; 362: 1491-1502Crossref PubMed Scopus (996) Google Scholar, 11Freeman M.L. Werner J. vanSantvoort H.C. et al.Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference.Pancreas. 2012; 41: 1176-1194Crossref PubMed Scopus (282) Google Scholar, 17Van Brunschot S. van Grinsven J. van Santvoort H.C. et al.Endoscopic or surgical step-up approach for infected necrotizing pancreatitis: a multicenter randomized trial.Lancet. 2018; 391: 51-58Abstract Full Text Full Text PDF PubMed Scopus (326) Google Scholar It must be appreciated that infected necrosis is a catabolic state, and source control is essential in those whose nutritional status is poor. Otherwise, some patients will deteriorate beyond the point of salvage, especially those with multiorgan failure. Necrotizing pancreatitis is a devastating disease that results in long term morbidity and problems—subjects that have rarely been investigated in prospective studies. The original landmark randomized trial by van Santvoort et al9van Santvoort H.C. Besselink M.G. Bakker O.J. et al.A step-up approach or open necrosectomy for necrotizing pancreatitis.N Engl J Med. 2010; 362: 1491-1502Crossref PubMed Scopus (996) Google Scholar (the PANTER trial), reported on in 2010, found that a minimally invasive step-up approach was associated with a significantly lower composite end point of major morbidity and mortality than an open surgical approach. Hollemans et al16Hollemans R.A. Bakker O.J. Boermeester M.A. et al.Superiority of step-up approach vs open necrosectomy in long-term follow-up of patients with necrotizing pancreatitis.Gastroenterology. 2019; 156: 1016-1026Abstract Full Text Full Text PDF Scopus (98) Google Scholar have reported the long-term follow-up of patients in that study who survived the illness after the index intervention. Of the 88 patients, 73 were alive and followed for a mean of 86 months. The primary outcome was similar to the original PANTER trial, consisting of a composite of major complications or death. Nineteen patients (44%) died or had major complications in the step-up group compared with 33 patients (73%) in the open necrosectomy group (P = .005). Significantly lower proportions of patients in the step-up group had incisional hernias (23% vs 53%; P = .004), pancreatic exocrine insufficiency (29% vs 56%; P = .03), or endocrine insufficiency (40% vs 64%; P = .05). A major reason for improved outcomes might be that necrosectomy was not required in 35% of the minimally invasive group, compared with all patients in the open group. There were no significant differences between the groups in proportions of patients requiring additional drainage procedures (11% vs 13%; P = .99), recurrent pancreatitis, or need for pancreatic surgery to treat long-term complications such as disconnected duct (11% vs 5%; P = .43). These data are reassuring and should be taken into consideration when advising patients about the choice of therapy. Even though the study showed reasonably good outcomes, long-term sequelae of necrotizing pancreatitis are well known. In a study of 578 patients, complications such as disconnected pancreatic duct syndrome (47.4%), splanchnic vein thrombosis (44.9%), insulin-dependent endocrine insufficiency (35.3%), exocrine insufficiency (18.9%), biliary stricture (15.6%), chronic pancreatitis (9.8%), chronic pain syndrome (7.7%), and gastrointestinal fistula (7.3%) were observed (N.J. Zyromski, unpublished data). These data suggest a need for periodic surveillance and continued care over an extended period of time. Many interventionalists, and especially endoscopists newly engaged in the field of necrotizing pancreatitis, might lose contact with patients after the initial intervention seems to be complete. With these advances, we must appreciate gaps in our current knowledge, such as the variable clinical trajectory of acute necrotizing pancreatitis, the need to develop objective metrics for time to step-up therapy, and the need for better outcome measures particularly in mid and long-term. These outcome measures should include return to functional activity and quality of life. Is open surgery “over and out”? Open surgery may still be required for patients with extensive necrosis who fail minimally invasive surgery, those with complications of pancreatitis such as bowel perforation, and complications of index intervention, such as endoscopy/laparoscopy-induced perforation and hemorrhage.22Roch A.M. Maatman T. Carr R.A. et al.Evolving treatment of necrotizing pancreatitis.Am J Surg. 2018; 215: 526-529Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar In 1 center with a 10-year history of aggressive endoscopically centered minimally invasive multimodal intervention for necrotizing pancreatitis, applied to nearly 300 patients, fully 7% of patients undergoing early intervention at <4 weeks required open surgery for salvage of refractory necrosis, or complications such as bowel perforation.20Trikudanathan G. Tawfik P. Amateau S.K. et al.Early (<4 weeks) versus standard (≥ 4 weeks) endoscopically centered step-up interventions for necrotizing pancreatitis.Am J Gastroenterol. 2018; 113: 1550-1558Crossref PubMed Scopus (68) Google Scholar What approach should we recommend for patients with infected necrosis? In those who are stable, but intervention is required because of clinical deterioration, either endoscopic drainage or a step-up approach with percutaneous drainage followed by VARD should be undertaken, depending on local expertise and the location of the collection. In patients with collections unsuitable for endoscopic drainage, percutaneous drainage should be the preferred approach. Percutaneous drainage is likely to provide at least short-term benefit to stabilize the majority of patients and may avoid further intervention in up to one-third of patients.9van Santvoort H.C. Besselink M.G. Bakker O.J. et al.A step-up approach or open necrosectomy for necrotizing pancreatitis.N Engl J Med. 2010; 362: 1491-1502Crossref PubMed Scopus (996) Google Scholar In selected patients with infected necrosis, a meta-analysis has shown that 64% could be treated successfully without the need for necrosectomy.23Mouli V.P. Sreenivas V. Garg P.K. Efficacy of conservative treatment, without necrosectomy, for infected pancreatic necrosis – a systematic review and meta-analysis.Gastroenterology. 2013; 144: 333-340Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar It should be noted that in both the MISER and TENSION trials, the endoscopically treated group was often treated before randomization, or after endoscopic intervention, with adjunctive percutaneous catheter drainage. Percutaneous drainage also provides opportunity for percutaneous endoscopic necrosectomy through the sinus tract.12Trikudanathan G. Attam R. Arain M.A. et al.Endoscopic interventions for necrotizing pancreatitis.Am J Gastroenterol. 2014; 109: 969-981Crossref PubMed Scopus (49) Google Scholar, 24Dhingra R. Srivastava S. Behra S. et al.Single or multiport percutaneous endoscopic necrosectomy performed with the patient under conscious sedation is a safe and effective treatment for infected pancreatic necrosis (with video).Gastrointest Endosc. 2015; 81: 351-359Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The importance of dual modality drainage, which is so often required for ill patients with extensive extrapancreatic necrosis, should not be overlooked by endoscopists jumping to conclusion that endoscopic therapy stands alone. Infected necrosis is a heterogeneous disease with marked variation in extent and course, such that “one size” treatment does not fit all. Both the TENSION and MISER trials included very selected groups of patients, and importantly, both trials were conducted by experienced groups with multidisciplinary input and support. Acute necrotizing pancreatitis is a disease that mandates a holistic team approach with a team comprised of GI physicians, endoscopists, interventional radiologists, intensivists, and surgeons to develop an individualized approach to each patient.22Roch A.M. Maatman T. Carr R.A. et al.Evolving treatment of necrotizing pancreatitis.Am J Surg. 2018; 215: 526-529Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Also, critical to the management of these patients is appreciation for the “long-term acute” disease process. Most patients will require care for months (and some up to and beyond 1 year) until resolution of the acute disease process. A dedicated team of physicians is necessary to follow this disease to completion, as well as to provide longer term interval follow-up of patients. In summary, the study by Bang et al15Bang J.Y. Arnoletti J.P. Holt B.A. et al.An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis.Gastroenterology. 2019; 156: 1027-1040Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar provides robust evidence that endoscopic therapy may be preferred over minimally invasive surgical approaches when performed by expert hands at specialized centers. The follow-up study by Hollemans et al16Hollemans R.A. Bakker O.J. Boermeester M.A. et al.Superiority of step-up approach vs open necrosectomy in long-term follow-up of patients with necrotizing pancreatitis.Gastroenterology. 2019; 156: 1016-1026Abstract Full Text Full Text PDF Scopus (98) Google Scholar has shown convincingly that minimally invasive approaches result in better long-term outcomes compared with open surgery in patients with infected necrosis. How the many modalities are integrated best for any individual patient, and at which centers and with which type of specialized team, still requires very careful consideration. Superiority of Step-up Approach vs Open Necrosectomy in Long-term Follow-up of Patients With Necrotizing PancreatitisGastroenterologyVol. 156Issue 4PreviewIn a 2010 randomized trial (the PANTER trial), a surgical step-up approach for infected necrotizing pancreatitis was found to reduce the composite endpoint of death or major complications compared with open necrosectomy; 35% of patients were successfully treated with simple catheter drainage only. There is concern, however, that minimally invasive treatment increases the need for reinterventions for residual peripancreatic necrotic collections and other complications during the long term. We therefore performed a long-term follow-up study. Full-Text PDF An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing PancreatitisGastroenterologyVol. 156Issue 4PreviewInfected necrotizing pancreatitis is a highly morbid disease with poor outcomes. Intervention strategies have progressed from open necrosectomy to minimally invasive approaches. We compared outcomes of minimally invasive surgery vs endoscopic approaches for patients with infected necrotizing pancreatitis. Full-Text PDF Open Access" @default.
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• W2912887184 title "Infected Necrotizing Pancreatitis: Evolving Interventional Strategies From Minimally Invasive Surgery to Endoscopic Therapy—Evidence Mounts, But One Size Does Not Fit All" @default.
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