Fewer long-term interventions after delayed drainage in necrotising pancreatitis

The comparison of immediate versus postponed drainage in the treatment of necrotising pancreatitis showed no significant benefit for either group in terms of mortality or major complications after 6 months. New long-term results of the POINTER trial showed similar results at 51 months of follow-up. No statistically significant difference was found in the primary endpoint but delayed drainage continued to result in a lower need for interventions.

In the previously published POINTER trial (ISRCTN33682933), patients with infected necrotic pancreatitis were randomised to an immediate drainage group or a postponed drainage group while being treated with antibiotics [1]. “This trial showed 2 important benefits of postponed intervention at the 6-month follow-up, which is that patients assigned to the postponed drainage group needed fewer interventions when compared with the immediate drainage group and that 35% of the patients were successfully treated with antibiotics only,” Ms Noor Sissingh (Leiden University Medical Centre, the Netherlands) explained. On behalf of the Dutch Pancreatitis Study Group, she presented the new POINTER follow-up study that aimed to clarify whether or not long-term results beyond the initial 6 months would uphold these results [2].

Of the 104 patients in the initial trial, 88 patients who were still alive after the initial 6-month follow-up were re-evaluated in the long-term analysis of immediate (e.g. drainage within 24 hours after randomisation once infected necrosis was diagnosed) versus postponed (e.g. drainage that was postponed until the stage of walled-off necrosis was reached) drainage with antibiotics, that defined a composite primary outcome of death or major complications. The baseline characteristics of the initial trial noted no overall differences between the groups. The time between randomisation and drainage was 1 day in the immediate drainage group and 9 days in the postponed drainage group.

The results distinguished between new events (>6 months) and all events within the total follow-up time that extended over a median of 51 months. The results did not show a statistical difference between the 2 drainage schedules for either of the result categories in the primary endpoint, nor in hospital stay or quality-of-life. “Regarding the interventions that were performed after the initial 6 months, you can see that 7 patients in the immediate drainage group needed another drainage procedure after this period, while this was needed for 3 patients in the postponed drainage arm. Also, it is good to mention that 1 of these was a patient that was initially treated with antibiotics only in the POINTER trial,” Ms Sissingh stressed.

Compared with all patients receiving drainage per design in the immediate group, only 65% in the postponed group needed drainage, leading to a relative risk of 1.53 (P<0.0001). Moreover, a lower fraction of patients needed a necrosectomy in the postponed drainage group (51% vs 22%; P=0.004). Only in the total follow-up results, the number of interventions was significantly lower in the postponed drainage arm.

Ms Sissingh underlined that even though there were no differences in death or major complications, hospital stay, and quality-of-life, the postponed drainage approach for infected necrotising pancreatitis continued to result in fewer interventions after the initial 6 months follow-up as compared with immediate drainage.

1. Boxhoorn L, et al. N Engl J Med 2021;385:1372–1381.
2. Van Veldhuisen C, et al. Long-term outcome of the POINTER randomised trial on immediate versus postponed intervention for infected necrotising pancreatitis. LB03, UEG Week 2022, 8–11 October, Vienna, Austria.

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Posted on 2 December, 2022