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Step-Up Approach Beneficial in Necrotizing Pancreatitis

Rate of major complications or death is lower than with open necrosectomy

WEDNESDAY, April 21 (HealthDay News) -- Among patients with necrotizing pancreatitis and infected necrotic tissue, a minimally invasive step-up approach may effectively reduce the rate of major complications or death compared with open necrosectomy, according to a study published in the April 22 issue of the New England Journal of Medicine.

Hjalmar C. van Santvoort, M.D., of the University Medical Center in Utrecht, Netherlands, and colleagues randomly assigned 88 patients with necrotizing pancreatitis and confirmed or suspected infected necrotic tissue to undergo either primary open necrosectomy or a step-up approach consisting of percutaneous drainage, followed, if necessary, by minimally invasive retroperitoneal necrosectomy.

The researchers found that the primary end point -- a composite of major complications (new-onset multiple-organ failure or multiple systemic complications; perforation of a visceral organ or enterocutaneous fistula; or bleeding) or death -- occurred in more patients assigned to open necrosectomy than those assigned to the step-up approach (69 versus 40 percent). They also found that new-onset multiple-organ failure occurred less often in patients assigned to the step-up approach than in those assigned to open necrosectomy (12 versus 40 percent). Although there were no significant group differences in the rate of death (19 versus 16 percent), they found that patients assigned to the step-up approach had a lower rate of incisional hernias (7 versus 24 percent) and new-onset diabetes (16 versus 38 percent).

"Despite its limitations, this is an excellent study," states the author of an accompanying editorial. "The feasibility and probable greater safety of the step-up approach to necrotizing pancreatitis is an important synthesis and integration of evolving techniques. As such, it is a major contribution that is likely to change our practice, at least for a segment of patients with severe acute pancreatitis."

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