Optimizing the step-up approach for infected necrotizing pancreatitis

The aim of the studies described in this thesis is to optimize the step-up approach in patients with infected necrotizing pancreatitis.
PART I decision-making on invasive interventions. The value of a 24/7 online nationwide multidisciplinary expert panel for necrotizing pancreatitis was assessed and considered a valuable and accessible tool. Opposed to traditional views, clinically relevant walled-off necrosis on computed tomography (CT) was often seen within the first 3 weeks (43% of patients). Skeletal muscle mass and density and visceral adipose tissue on first CT were not independently associated with in-hospital mortality. Although, a significant decrease in muscle mass and muscle density was seen over the first month after hospital admission.
PART II drainage and debridement techniques. A proactive percutaneous catheter drainage (PCD) strategy, including frequent and early drain revising and upsizing, reduced the need for surgical necrosectomy compared to a standard PCD strategy (29% versus 52%). In the TENSION trial the endoscopic step-up approach was not superior to the surgical step-up approach in infected necrotizing pancreatitis concerning the primary end point of major complications and death. But the rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group (respectively 5% vs. 32% and mean 53 vs. 69 days).
PART III timing of primary catheter drainage. A systematic literature search revealed that data on timing of primary catheter drainage is lacking. Also in an international expert survey there was no consensus on this topic. Therefore the randomized POINTER trial was designed to investigate whether immediate catheter drainage is superior to the current practice of postponing intervention until the stage of walled-off necrosis.