Sometimes the pancreas becomes so severely injured or infected, its tissue dies or necrotizes. The condition, known as necrotizing pancreatitis, can result in a range of serious complications and can be deadly. Treatment requires removal of the infected tissue in the pancreas.
Digestive health specialists at Orlando Health Digestive Health Institute have led research that shows a new treatment approach to treat necrotizing pancreatitis takes less time and improves outcomes, yielding more benefits to patients.
The findings from the multicenter randomized trial Direct Endoscopic versus Step-up Transluminal Interventions in Infected Necrotizing Pancreatitis (DESTIN), were recently published in The Lancet Gastroenterology & Hepatology. The study examined two possible treatment plans for necrotizing pancreatitis: an Upfront necrosectomy and a step-up endoscopic approach.
“This is the first study in the World that compared these two treatment options and come out with definitive conclusions,” said Dr. Varadarajulu. “The findings are expected to alter the current standards for treatment of severe pancreatitis worldwide.
In the study, investigators found the upfront treatment on average was associated with a need for fewer interventions per patient (one compared to two), a shorter hospital stay (nine days compared to 19 days) and a cost savings of $275,000 per patient. More importantly, the newly proposed upfront treatment was associated with no mortality as compared to six percent for the step-up approach.
“Traditionally, infected tissue removal was performed surgically by making a large external incision with high mortality of 20 to 90 percent,” said Shyam S. Varadarajulu, MD, president, Orlando Health Digestive Health Institute. “More recently, less invasive methods have been developed. Rather than making the large external incision, doctors now use a flexible endoscope passed via the mouth. A stent is placed as a first-step between the stomach wall and the pancreas to allow drainage of infected necrosis. If the patient does not respond to this treatment, after a few days or weeks, as a second-step, the endoscope is passed through the stent into the pancreatic bed for removal of necrosis. This is called step-up approach and is associated with mortality of 10 percent, which is lower than the traditional surgical method. However, patients may have to stay longer in the hospital, sometimes as long as 4-6 months, and is associated with high costs.”
During upfront necrosectomy, the necrotic tissue is removed immediately at the same setting after stent placement. The investigators found that the newly proposed upfront approach facilitates faster recovery, expedites hospital discharge and lowers costs.
Pancreatitis or inflammation of the pancreas is the third most common reason for inpatient hospitalization in the United States. In 20 percent of patients the inflammation can be very severe leading to the nonviable tissue called pancreatic necrosis. When there is superimposed infection, it is called infected necrotizing pancreatitis and carries a mortality of more than 20 percent.
Symptoms of pancreatitis include severe abdominal pain and fever. When infection develops in the setting of necrosis, patients develop sepsis and organ dysfunction such as respiratory or renal failure that warrants an urgent intervention.
The Orlando Health Digestive Health Institute was the lead site to the multicenter study made up of health care organizations from across the country and world. The satellite centers were University of Southern California in LA, University of West Virgnia in Morgantown, RUSH University in Chicago, and Asian Institute of Gastroenterology in India. The Institute leads a consortium called the United States Pancreatic Disease Study Group (USPG) which is comprised of the top 50 academic medical centers in the country that pursue cutting edge clinical research in diseases of the pancreas.
In addition to the DESTIN trial, the Orlando Health Digestive Health Institute is currently conducting more than 15 clinical trials and its faculty have published more than 1,000 peer reviewed publications, particularly on endoscopic treatment of pancreatitis, more than any other institution in the United States.