Simultaneous Drainage versus Step-Up Therapy for Drainage of Multiple Infected Pancreatic Necrotic Collections in Patients with Acute Necrotizing Pancreatitis: A Randomized Trial

Background: Minimally invasive step-up approach is the recommended modality of treatment in patients with infected pancreatic necrosis (IPN). Majority of patients with pancreatic collections have a single IPN; however, some patients do have multiple IPNs. In such scenario, whether drainage of all collections simultaneously has better clinical outcome compared to draining collections sequentially as per clinical response has not been explored. We performed a single center, open label, randomized trial to compare sequential vs simultaneous drainage of multiple IPNs in patients with acute necrotizing pancreatitis (ANP).

Methods: All consecutive patients of acute pancreatitis with multiple confirmed or clinically suspected IPN were screened. In simultaneous group (group A), all independent collections were intervened simultaneously using either endoscopic or percutaneous approach. In sequential group (group B), only collection with larger size or gas configuration was intervened. Additional interventions in either group were done as per pre-defined criteria. Primary outcome was the score on Comprehensive Complication Index (CCI) till clinical success. Secondary outcomes were number of interventions required for clinical success, new onset organ failure, major disease/procedure related complications and mortality (CTRI/2022/07/043878).

Results: A total of 60 patients with multiple IPNs were enrolled (29 in group A and 31 in group B). All patients had ongoing SIRS and 66.6% (n = 40) patients had ongoing organ failure. Mean CCI was 72.48 ± 28.28 in group A and 64.43 ± 34.91 in group B (p = 0.332). Total interventions were lower in group B (4.55 ± 2.21 vs. 3.23 ± 2.14; p = 0.022). Development of new-onset organ failure (34.5% vs. 38.7%; p = 0.734), requirement of surgical intervention (27.6% vs. 22.6%; p = 0.655), and mortality (41.3% vs. 38.7%; p = 0.833) were equal amongst both groups.

Conclusion: Sequential drainage tailored according to the clinical response has equivalent clinical outcome with fewer requirement of interventions compared to simultaneous drainage of all collections in patients with multiple IPNs.

Publication History

Article published online:
22 April 2024