title: A step-up approach or open necrosectomy for necrotizing pancreatitis.
abstract: BACKGROUND
  Necrotizing pancreatitis with infected necrotic tissue is associated with a high rate of complications and death. Standard treatment is open necrosectomy. The outcome may be improved by a minimally invasive step-up approach.
  
  
  METHODS
  In this multicenter study, we randomly assigned 88 patients with necrotizing pancreatitis and suspected or confirmed infected necrotic tissue to undergo primary open necrosectomy or a step-up approach to treatment. The step-up approach consisted of percutaneous drainage followed, if necessary, by minimally invasive retroperitoneal necrosectomy. The primary end point was 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.
  
  
  RESULTS
  The primary end point occurred in 31 of 45 patients (69%) assigned to open necrosectomy and in 17 of 43 patients (40%) assigned to the step-up approach (risk ratio with the step-up approach, 0.57; 95% confidence interval, 0.38 to 0.87; P=0.006). Of the patients assigned to the step-up approach, 35% were treated with percutaneous drainage only. New-onset multiple-organ failure occurred less often in patients assigned to the step-up approach than in those assigned to open necrosectomy (12% vs. 40%, P=0.002). The rate of death did not differ significantly between groups (19% vs. 16%, P=0.70). Patients assigned to the step-up approach had a lower rate of incisional hernias (7% vs. 24%, P=0.03) and new-onset diabetes (16% vs. 38%, P=0.02).
  
  
  CONCLUSIONS
  A minimally invasive step-up approach, as compared with open necrosectomy, reduced the rate of the composite end point of major complications or death among patients with necrotizing pancreatitis and infected necrotic tissue. (Current Controlled Trials number, ISRCTN13975868.)
authors.affiliation: University Medical Center, Utrecht, The Netherlands.
authors.forename: Hjalmar C
authors.initials: HC
authors.lastname: van Santvoort
authors.forename: Marc G
authors.initials: MG
authors.lastname: Besselink
authors.forename: Olaf J
authors.initials: OJ
authors.lastname: Bakker
authors.forename: H Sijbrand
authors.initials: HS
authors.lastname: Hofker
authors.forename: Marja A
authors.initials: MA
authors.lastname: Boermeester
authors.forename: Cornelis H
authors.initials: CH
authors.lastname: Dejong
authors.forename: Harry
authors.initials: H
authors.lastname: van Goor
authors.forename: Alexander F
authors.initials: AF
authors.lastname: Schaapherder
authors.forename: Casper H
authors.initials: CH
authors.lastname: van Eijck
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Bollen
authors.forename: Bert
authors.initials: B
authors.lastname: van Ramshorst
authors.forename: Vincent B
authors.initials: VB
authors.lastname: Nieuwenhuijs
authors.forename: Robin
authors.initials: R
authors.lastname: Timmer
authors.forename: Johan S
authors.initials: JS
authors.lastname: Laméris
authors.forename: Philip M
authors.initials: PM
authors.lastname: Kruyt
authors.forename: Eric R
authors.initials: ER
authors.lastname: Manusama
authors.forename: Erwin
authors.initials: E
authors.lastname: van der Harst
authors.forename: George P
authors.initials: GP
authors.lastname: van der Schelling
authors.forename: Tom
authors.initials: T
authors.lastname: Karsten
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Hesselink
authors.forename: Cornelis J
authors.initials: CJ
authors.lastname: van Laarhoven
authors.forename: Camiel
authors.initials: C
authors.lastname: Rosman
authors.forename: Koop
authors.initials: K
authors.lastname: Bosscha
authors.forename: Ralph J
authors.initials: RJ
authors.lastname: de Wit
authors.forename: Alexander P
authors.initials: AP
authors.lastname: Houdijk
authors.forename: Maarten S
authors.initials: MS
authors.lastname: van Leeuwen
authors.forename: Erik
authors.initials: E
authors.lastname: Buskens
authors.forename: Hein G
authors.initials: HG
authors.lastname: Gooszen
mesh_terms: D003646:Debridement; D004322:Drainage; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D009102:Multiple Organ Failure / Q000517:prevention & control; D010179:Pancreas / Q000601:surgery*; D019283:Pancreatitis, Acute Necrotizing / Q000401:mortality / Q000601:surgery*; D011183:Postoperative Complications / Q000517:prevention & control; D011786:Quality Control; D020535:Video-Assisted Surgery