title: Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial.
abstract: BACKGROUND
  Most patients with infected necrotizing pancreatitis require necrosectomy. Surgical necrosectomy induces a proinflammatory response and is associated with a high complication rate. Endoscopic transgastric necrosectomy, a form of natural orifice transluminal endoscopic surgery, may reduce the proinflammatory response and reduce complications.
  
  
  OBJECTIVE
  To compare the proinflammatory response and clinical outcome of endoscopic transgastric and surgical necrosectomy.
  
  
  METHODS
  Randomized controlled assessor-blinded clinical trial in 3 academic hospitals and 1 regional teaching hospital in The Netherlands between August 20, 2008, and March 3, 2010. Patients had signs of infected necrotizing pancreatitis and an indication for intervention.
  
  
  METHODS
  Random allocation to endoscopic transgastric or surgical necrosectomy. Endoscopic necrosectomy consisted of transgastric puncture, balloon dilatation, retroperitoneal drainage, and necrosectomy. Surgical necrosectomy consisted of video-assisted retroperitoneal debridement or, if not feasible, laparotomy.
  
  
  METHODS
  The primary end point was the postprocedural proinflammatory response as measured by serum interleukin 6 (IL-6) levels. Secondary clinical end points included a predefined composite end point of major complications (new-onset multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, or pancreatic fistula) or death.
  
  
  RESULTS
  We randomized 22 patients, 2 of whom did not undergo necrosectomy following percutaneous catheter drainage and could not be analyzed for the primary end point. Endoscopic transgastric necrosectomy reduced the postprocedural IL-6 levels compared with surgical necrosectomy (P = .004). The composite clinical end point occurred less often after endoscopic necrosectomy (20% vs 80%; risk difference [RD], 0.60; 95% CI, 0.16-0.80; P = .03). Endoscopic necrosectomy did not cause new-onset multiple organ failure (0% vs 50%, RD, 0.50; 95% CI, 0.12-0.76; P = .03) and reduced the number of pancreatic fistulas (10% vs 70%; RD, 0.60; 95% CI, 0.17-0.81; P = .02).
  
  
  CONCLUSIONS
  In patients with infected necrotizing pancreatitis, endoscopic necrosectomy reduced the proinflammatory response as well as the composite clinical end point compared with surgical necrosectomy.
  
  
  BACKGROUND
  isrctn.org Identifier: ISRCTN07091918.
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. o.j.bakker@umcutrecht.nl
authors.forename: Olaf J
authors.initials: OJ
authors.lastname: Bakker
authors.forename: Hjalmar C
authors.initials: HC
authors.lastname: van Santvoort
authors.forename: Sandra
authors.initials: S
authors.lastname: van Brunschot
authors.forename: Ronald B
authors.initials: RB
authors.lastname: Geskus
authors.forename: Marc G
authors.initials: MG
authors.lastname: Besselink
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Bollen
authors.forename: Casper H
authors.initials: CH
authors.lastname: van Eijck
authors.forename: Paul
authors.initials: P
authors.lastname: Fockens
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Hazebroek
authors.forename: Rian M
authors.initials: RM
authors.lastname: Nijmeijer
authors.forename: Jan-Werner
authors.initials: JW
authors.lastname: Poley
authors.forename: Bert
authors.initials: B
authors.lastname: van Ramshorst
authors.forename: Frank P
authors.initials: FP
authors.lastname: Vleggaar
authors.forename: Marja A
authors.initials: MA
authors.lastname: Boermeester
authors.forename: Hein G
authors.initials: HG
authors.lastname: Gooszen
authors.forename: Bas L
authors.initials: BL
authors.lastname: Weusten
authors.forename: Robin
authors.initials: R
authors.lastname: Timmer
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000097:blood; D053704:Capsule Endoscopy; D005260:Female; D006801:Humans; D007239:Infections / Q000150:complications; D007249:Inflammation / Q000517:prevention & control*; D015850:Interleukin-6 / Q000097:blood; D007813:Laparotomy; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D019283:Pancreatitis, Acute Necrotizing / Q000150:complications / Q000601:surgery*; D011183:Postoperative Complications / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D015850:Interleukin-6