A Clinical Study On The Timing And Indications Of Intervention In Patients With Acute Necrotizing Pancreatitis Complicated By Persistent Organ Failure

Part oneBackground: The optimal management strategy in acute necrotizing pancreatitis(ANP)is debated,and compliance with current guidelines in China is not known.In this study,we performed a national survey on the optimal management strategy in ANP in China firstly.Methods: An online questionnaire about the diagnosis and treatment of local complications of ANP was distributed through a national collaborative network.The local and systemic complications were defined according to the Revised Atlanta Classification.Results: There were 321 survey respondents from 208 hospitals located in 30/34 provinces across China.There was a lack of consensus in terms of early diagnosis of infected pancreatic necrosis(IPN)as the respondents chose to depend on clinical symptoms(70/321,22%),organ failure(82/321,26%),imaging changes(84/321,26%),and fine needle aspiration(51/321,16%),respectively.A ‘step-up' approach has been widely adopted in patients with IPN(294/321,92%).The decision for initial intervention(without confirmed/ suspected infection)was based on clinical condition for most respondents(71%).Conclusion: While the ‘step-up' approach has been widely adopted there is still significant variation in regards to the diagnosis of infection,the best timing and the indications for early intervention.Part twoBackground: In acute pancreatitis patients with persistent organ failure(POF),the current standard care for acute necrotic collections(ANC)is to postpone invasive intervention for four weeks when indicated,which may prolong organ failure.In this study,we aimed to assess the feasibility and safety of earlier drainage for acute pancreatitis patients with ANC and POF.Methods: A single-center,randomized controlled trial was conducted.Eligible patients were randomly assigned to either the early on-demand(EOD)group or the standard management(SM)group.Within 21 days of randomization,early drainage was triggered by unremitted or worsening organ failure in the EOD group.The primary endpoint was a composite of major complications/death during 90-days follow-up.Results: 30 patients were randomized.Within 21 days of randomization,8/15 patients(53%)in the EOD group underwent percutaneous drainage,while 4/15 patients(27%)in the SM group did so(P=0.26).The primary outcome occurred in 3/15(20%)patients in the EOD group and 7/15(46.7%)in the controls(p=0.25,relative risk 0.43,95%CI 0.14 to1.35).Conclusion: In patients with POF,the EOD approach did not result in significant differences between groups,but the primary outcome assessed in this trial demonstrated the potential for clinical benefits favoring early drainage.