The PANTER trial: Open necrosectomy vs step-up approach for necrotizing pancreatitis [Classics Series]

1. A minimally invasive step-up approach significantly reduced the rate of major complications as compared to open necrosectomy in patients with necrotizing pancreatitis

Original Date of Publication: April 22, 2010

Study Rundown: Necrotizing pancreatitis with infected necrotic tissue is associated with high rates of both complication and death. Though first-line treatment is open necrosectomy, this study compares this with a minimally invasive step-up approach, consisting of percutaneous drainage, endoscopic drainage, and/or minimally invasive retroperotineal necrosectomy. The incidence of multiple organ failure was significantly lower in patients who underwent the step-up approach compared with those who had open necrosectomy. Though the rate of death did not differ significantly between the two groups, patients who were assigned to the step-up approach faced significantly lower rates of both incisional hernias and new-onset diabetes. One limitation of the study was that it was not powered to detect significant differences in death between the two groups.

Click to read the study in NEJM

In-Depth [randomized, controlled study]: Originally published in NEJM in 2010, this multicenter, randomized, controlled study involved 88 patients with acute pancreatitis and pancreatic necrosis. They were randomized to receive treatment with either open necrosectomy or a step-up approach, which included percutaneous or endoscopic drainage, and minimally invasive retroperitoneal necrosectomy. The primary end point was a composite of complications (i.e., new-onset multiple-organ failure, multiple systemic complications, bleeding, perforation of a visceral organ) and death. Patients managed using the step-up approach experienced a significantly lower rate of the composite primary end point compared to those treated with open necrosectomy (RR 0.57; 95%CI 0.38-0.87). This was largely driven by a significant reduction in new-onset organ failure (12% vs. 40%, P=0.002), as there was no significant difference between the two groups in mortality. After six months of follow-up, patients who underwent open necrosectomy had a higher rate of incisional hernias (RR 0.29; 95%CI 0.09-0.95), new-onset diabetes (RR 0.43; 95%CI 0.20-0.94) and use of pancreatic enzymes (RR 0.21; 95%CI 0.07-0.67) when compared to those treated with the step-up approach. The study suggests that when treating necrotizing pancreatitis patients, a minimally invasive step-up approach reduces the rate of major complications and long-term complications when compared to open necrosectomy.

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