Infected Necrotizing Pancreatitis: A Pancreatologist’s Achilles Heel

Featured Articles:

Van Brunschot S, van Grinsven J, van Santvoort HC et al. Endoscopic or surgical step-up approach for infected necrotizing pancreatitis: a multicenter randomized trial. Lancet 2018;391:51-8.

MISER Trial:

Bang JY, Arnoletti JP, Holt BA et al. An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis. Gastroenterology 2019156:1027-1040.


Garg PK, Zyromski NJ, Freeman ML. Infected Necrotizing Pancreatitis: Evolving Interventional Strategies From Minimally Invasive Surgery to Endoscopic Therapy-Evidence Mounts, But One Size Does Not Fit All. Gastroenterology 2019;156:867-871.


Necrotizing pancreatitis occurs in up to 20% of patients with acute pancreatitis. Infection of necrotic fluid collections is an ominous development and independent determinant of survival. Interventions for infected Necrosis (IN) were the domain of open surgery. A Dutch multicenter randomized PANTER trial showed that step-up therapy from percutaneous catheter drainage to minimally invasive surgery, done through video assisted retroperitoneal debridement (VARD), was as effective as open surgery but with less complications. Simultaneous development in endoscopic transluminal therapy of pseudocysts and necrotic collections paved the way for a minimally invasive approach to necrosectomy including IN. Two recent studies on the evolving treatment of IN add to our knowledge regarding this challenging problem. In a randomized trial comparing endoscopic transluminal therapy with minimally invasive surgery – the TENSION trial by the Dutch study group showed that the minimally invasive surgical step up and endoscopic step-up approaches were similar in terms of composite end point (43% vs. 45%) in a study of 98 patients. The MISER trial by Bang et al showed that the composite primary outcome (new onset organ failure, enteral or pancreatic-cutaneous fistula, bleeding, perforation of visceral organ, or death during 6-month follow-up) was significantly less frequent in the endoscopy group compared with the minimally invasive surgery group (11.8% vs. 40.6%; p=0.007) in patients with suspected/proven infected necrosis. There was no significant difference in all-cause mortality in both the trials. There were some differences between the 2 trials. The most important being inclusion of fistulae in the major composite endpoint in the MISER study – in large part explaining the disparity in conclusions – the MISER Trial showed that the endoscopic approach was superior while the TENSION trial did not.

Infected necrosis is a heterogeneous disease with marked variation in disease characteristics and host response.  Both the TENSION and MISER trials included very selected groups of patients, and were conducted by experienced operators. Acute necrotizing pancreatitis is a disease that mandates a holistic team approach to individualized management of patients. A recent editorial aptly emphasized that “one size” treatment does not fit all patients with infected necrotizjng pancreatitis.