Invasive intervention timing for infected necrotizing pancreatitis: Late invasive intervention is not late for collection

Table 1 Major randomized controlled trials guiding the invasive intervention strategies for infected necrotizing pancreatitis

Years	First authors	RCTs	Study group (n)	Control group (n)	Main results	Conclusions
2010	Hjalmar C van Santvoort	PANTER	Step-up approach (n = 43, including 41 percutaneous drainage and 2 endoscopic drainages, 24 of them underwent VARD)	Open necrosectomy (n = 45, including 44 laparotomies and 1 VARD)	(1) Major complications or death (40% vs 69%); (2) New-onset multiple organ failure y (12% vs 40%); and (3) Incisional hernias (7% vs 24%)	A minimally invasive step-up approach, as compared with open necrosectomy, reduced the rate of the composite endpoint of major complications or death among patients with INP
2012	Olaf J Bakker	PENGUIN	Endoscopic transgastric necrosectomy (n = 10)	Surgical necrosectomy (n = 10, including 6 VARDs and 4 laparotomies)	(1) IL-6 levels increased after surgical necrosectomy, but decreased after endoscopy; (2) Composite clinical endpoint (20% vs 80%); (3) New-onset multiple organ (0 vs 50%); and (4) Pancreatic fistulas (10% vs 70%)	Endoscopic necrosectomy reduced the pro-inflammatory response as well as the composite clinical endpoint compared with surgical necrosectomy
2018	Sandra van Brunschot	TENSION	Endoscopic step-up approach (n = 51, including 22 endoscopic drainage only and 27 endoscopic necrosectomies and 2 VARD)	Surgical step-upapproach (n = 47, including 24 percutaneous drainages only and 23 VARDs)	(1) Major complications or death during 6-month follow-up (43% vs 45%); (2) Mortality (18% vs 13%); (3) Pancreatic fistulas (5% vs 32%); and (4) Hospital stay (35 d vs 65 d)	The endoscopic step-up approach was not superior to the surgical step-up approach in reducing major complications or death. The rate of pancreatic fistulas and length of hospital stay were lower in the endoscopy group
2019	Ji Young Bang	MISER	Endoscopic step-up approach (n = 34)	Minimally invasive surgery (n = 32, including 26 laparoscopic cystogastrostomy and 6 VARDs)	(1) Major complications or death (11.8% vs 40.6%); (2) The rate of SIRS at 72 hours after intervention (20.6% vs 65.6%); (3) Disease-related adverse events (5.9% vs 43.8%); and (4) The average total cost ($75830 vs $117492)	An endoscopic transluminal approach for INP, compared with minimally invasive surgery, significantly reduced major complications, lowered costs, and increased quality of life
2021	L Boxhoorn	POINTER	Immediate drainage within 24 hours once INP was diagnosed (n = 55)	Postponed drainage until the stage of WON (n = 49)	(1) The mean score on the Comprehensive Complication Index (57 vs 58); (2) Mortality (13% vs 10%); and (3) The mean number of interventions (4.4 vs 2.6)	Immediate drainage did not show superiority over postponed drainage concerning complications. Patients with the postponed-drainage strategy received fewer invasive interventions

INP: Infected necrotizing pancreatitis; VARD: Videoscope assisted retroperitoneal debridement; RCT: Randomized controlled trial.