Early versus delayed intervention in necrotizing acute pancreatitis complicated by persistent organ failure

When to Intervene in Acute Necrotizing Pancreatitis: A Narrative Review of the Optimal Timing for Intervention Strategies

Introduction: Acute necrotizing pancreatitis (ANP) is the acute inflammation of pancreatic parenchyma, most commonly due to alcohol abuse or cholelithiasis. The treatment can be either conservative or invasive, including a variety of techniques; however, it has not yet been established if the intervention should be early or if it should be delayed. The aim of this review is to investigate the optimal time for intervention in ANP. Methods: A literature search was conducted in PubMed and Scopus from inception until September 2024 for studies reporting the comparison between early and late intervention. Results: Early intervention, within 4 weeks of symptom onset, often involves drainage via percutaneous, endoscopic, or combined methods. Delayed intervention occurs after 4 weeks of symptom onset. This can be conducted either surgically or via minimally invasive means. The results of this review reveal that the time of intervention for ANP plays an important role in the prognosis and the course of the disease. In particular, early intervention is associated with higher mortality, which is also the primary clinical outcome. Delayed intervention is also superior regarding secondary clinical outcomes, specifically the complications associated with the intervention. Thus, it is accompanied by fewer episodes of new-onset organ failure, bleeding, gastrointestinal fistula, pancreatic fistula, wound infection, endocrine pancreatic insufficiency, and other complications. Finally, delayed intervention results in shorter stays, both in hospitals and the ICU. Conclusions: Delayed intervention is clearly more effective than early intervention and should be preferred. However, early intervention appears to be both safe and effective, and it is feasible.

To Drain or Not: Drainage Procedures Remain a Central Tenet of Management of Infected Collections in Acute Pancreatitis

Recent literature advocates for delayed or avoidance of catheter drainage of infected peri-pancreatic collections (IPCs) in acute pancreatitis (AP). This may not be realistic for patients at academic centers, many of whom are critically ill. We retrospectively reviewed 72 patients admitted to our institution from 2016-2021 with AP and IPCs. 34.7% had a Bedside Index of Severity in Acute Pancreatitis (BISAP) score ≥3, and 56.9% had a Balthazar score of E. 65.3% were admitted to the ICU, 51.4% experienced respiratory failure, and 47.2% had acute renal failure. In-hospital mortality was 9.7%. Catheter-based drainage alone was the most frequent intervention. Only 8 individuals did not undergo any drainage. Individuals with severe AP complicated by IPCs are critically ill. Avoidance or delay of source control could lead to significant morbidity. Until further research is done on this population, drainage should remain a central tenet of management of IPCs.

Comparison of early and late intervention for necrotizing pancreatitis: A systematic review and meta-analysis

OBJECTIVES

Postponed open necrosectomy or minimally invasive intervention has become the treatment option for necrotizing pancreatitis. Nevertheless, several studies point to the safety and efficacy of early intervention for necrotizing pancreatitis. Therefore, we conducted a systematic review and meta-analysis to compare clinical outcomes of acute necrotizing pancreatitis between early and late intervention.

METHODS

Literature search was performed in multiple databases for articles that compared the safety and clinical outcomes of early (<4 weeks from the onset of pancreatitis) versus late intervention (≥4 weeks from the onset of pancreatitis) for necrotizing pancreatitis published up to August 31, 2022. The meta-analysis was performed to determine pooled odds ratio (OR) of mortality rate and procedure-related complications.

RESULTS

Fourteen studies were included in the final analysis. For open necrosectomy intervention, the overall pooled OR of mortality rate with the late intervention compared with early intervention was 7.09 (95% confidence interval [CI] 2.33-21.60; I2  = 54%; P = 0.0006). For minimally invasive intervention, the overall pooled OR of mortality rate with the late intervention compared with early intervention was 1.56 (95% CI 1.11-2.20; I2  = 0%; P = 0.01). The overall pooled OR of pancreatic fistula with the late minimally invasive intervention compared with early intervention was 2.49 (95% CI 1.75-3.52; I2  = 0%; P < 0.00001).

CONCLUSION

These results showed the benefit of late interventions in patients with necrotizing pancreatitis in both minimally invasive procedures and open necrosectomy. Late intervention is preferred in the management of necrotizing pancreatitis.

Timing of minimally invasive step-up intervention for symptomatic pancreatic necrotic fluid collections: A systematic review and meta-analysis

BACKGROUND AND AIMS

Minimally invasive step-up interventions are now the standard treatment recommended by current guidelines for symptomatic pancreatic necrotic fluid collections (PNFC); however, it is controversial whether delayed treatment after four weeks should always be used in patients who have failed conservative treatment and whose condition has not improved or worsened. The aim of this meta-analysis was to evaluate the impacts of the different timing of interventions on the clinical outcomes and prognosis of patients with symptomatic PNEC requiring intervention.

METHODS

We searched Embase, Cochrane Library, PubMed and Web of Science databases to identify comparative studies assessing the safety and efficacy of early and postponed interventions in treating symptomatic PNFC.

PRIMARY OUTCOME

Mortality. Secondary outcomes included some major complications, need for further minimally invasive necrosectomy and length of hospital stay.

RESULTS

This meta-analysis included ten studies (2 RCTs and 8 observational studies) with a total of 1178 symptomatic PNFC patients who required intervention. Pooled results showed that there was no significant difference between early minimally invasive intervention and postponed intervention in mortality(OR 1.41, 95%CI 0.93-2.12;p = 0.10) and the incidence of early and late complications, but the early intervention group had a significantly increased need for further minimally invasive necrosectomy compared with postponed intervention (OR 2.04,95%CI 1.04-4.03; p = 0.04). There was no increase in length of stay for patients who received early intervention compared to postponed drainage (MD 3.53, 95% CI -4.20, 11.27; p = 0.37).

CONCLUSION

Intervention before four weeks should be considered for patients with PNFC complicated by persistent organ failure or infections, who have been treated conservatively to the maximum extent possible.

Early versus delayed interventions for necrotizing pancreatitis: A systematic review and meta-analysis

Objectives

Interventions for necrotizing pancreatitis are generally postponed until 4 weeks after the onset of acute pancreatitis, but there remains controversy about whether we should always wait >4 weeks or can intervene early when necessary. This meta‐analysis was conducted to evaluate treatment outcomes of necrotizing pancreatitis according to the cut‐off defined in the revised Atlanta classification (≤4 vs. >4 weeks).

Methods

Using PubMed, Web of Science, and the Cochrane database, we identified clinical studies published until March 2022 with data comparing outcomes of early and delayed interventions of necrotizing pancreatitis. We pooled data on adverse events, mortality, technical and clinical success rates, and needs for necrosectomy and open surgery, using the random‐effects model.

Results

We identified 11 retrospective studies, including 775 patients with early interventions and 725 patients with delayed interventions. Patients with early interventions tended to be complicated by organ failure. The rate of adverse events was comparable (OR 1.41, 95% CI 0.66–3.01; p = 0.38) but the rate of mortality was significantly higher (OR 1.70, 95% CI 1.21–2.40; p < 0.01) in early interventions. Technical success rates were similarly high but clinical success rates tended to be low (OR 0.39, 95% CI 0.15–1.00; p = 0.05) in early interventions, though not statistically significant. Pooled ORs for necrosectomy and open surgery were 2.14 and 1.23, respectively.

Conclusions

Early interventions for necrotizing pancreatitis were associated with higher mortality rates and did not reduce adverse events or improve clinical success. However, our results should be confirmed in prospective studies.

The clinical outcome from early versus delayed minimally invasive intervention for infected pancreatic necrosis: a systematic review and meta-analysis

BACKGROUND

While the management of infected pancreatic necrosis (IPN) has evolved in the last two decades with the adoption of minimally invasive interventions (drainage ± debridement), it is unknown whether the principle of delaying intervention inherited from the open surgery era still applies. The aim of the current study was to investigate the impact of the timing of minimally invasive intervention on the outcomes of patients with IPN requiring intervention.

METHODS

PubMed, Embase, MEDLINE and Web of Science databases were searched for appropriate studies. The primary outcome of interest was hospital mortality, the secondary outcomes were the incidence of complications during the hospitalization, including new-onset organ failure, gastrointestinal fistula or perforation, bleeding and length of hospital or intensive care unit (ICU) stay.

RESULTS

Seven clinical studies were included with a total of 742 patients with IPN requiring intervention, of whom 321 received early intervention and 421 delayed intervention. Results from the meta-analysis showed that early minimally invasive intervention did not increase hospital mortality (odds ratio 1.65, 95% confidence interval 0.97-2.81; p = 0.06) but was associated with a remarkably prolonged hospital stay and an increased incidence of gastrointestinal fistula or perforation when compared with delayed intervention.

CONCLUSIONS

Although no firm conclusion can be drawn because of the quality of available studies, it does appear that timing of intervention is a risk factor for adverse outcomes and ought to be investigated more rigorously in prospective studies.