Thread by @AmCollegeGastro

1/ It's #EBGI Tweetorial 🧵 w/ @aileenbui!

“Drainage for Infected Pancreatic Necrosis – Earlier Is Not Better"

📜 Summary: bit.ly/3kONaEQ
📰 in @NEJM: bit.ly/3MWe4X5

@SunilAminMD @KumarShria
@MarcBesselink @pancreatitis_nl
#GITwitter #MedTwitter

2/ Let’s start with a poll:

40 yo 🙎🏻‍♂️ w/ worsening signs of sepsis 14 days after initial dx of acute pancreatitis. CT A/P w/ gas in the area of pancreatic necrosis.

What do you do?

3/ Importance

🔸1/3 of pancreatic necrosis ➡️ infected (after ~10 days)
🔸Infection 🦠 ➡️ 20-30% mortality
🔸Management is usually step⬆️, see 👇
🔸But, the timing of catheter drainage is unclear

4/ 🔎 Design

📍RCT in 🇳🇱
📍Patients 👥 with infected necrosis
📍Randomized to immediate vs delayed drainage
📍If clinical decompensation ➡️ drain earlier
📍If drainage fails ➡️✂️
📍All 👥 received abx immediately after dx of 🦠
📍Primary outcome: Comprehensive Complication Index

5/ 🔎findings

✳️ No difference in the Comprehensive Complication Index
✳️ No difference in mortality and organ failure
✳️ No difference in cost or length of stay
✳️ ⬇️ interventions in postponed drainage group
✳️ 40% of postponed drainage group treated w/ abx alone
@gooreducatie

6/ ⚠️Caution⚠️

❗️37 👥 died prior to randomization
❗️🕑 drainage after symptom onset: 24 days (immediate) vs 34 days (delayed)
❗️Postponed drainage may not be suitable for all 👥
❗️Trial excluded 👥 where drainage was unfeasible
❗️Trial evaluated🕑 of intervention, not method

7/ My Practice
@SunilAminMD @KumarShria
✅ Abx that penetrate necrosis in all 👥
✅ Delay drainage until collection walled off (~ 4 weeks)
✅ Endoscopic approach 1st, unless ❌ location or <4wks from pancreatitis onset
✅ Percutaneous drainage if endoscopic approach not possible

8/ Thank you! Check us out at gi.org/ebgi

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