Article 1
Immediate versus Postponed Intervention for Infected Necrotizing Pancreatitis. Boxhoorn L, van Dijk SM, van Grinsven J, Verdonk RC, Boermeester MA, Bollen TL, et al. N Engl J Med. 2021 Oct 7;385(15):1372-1381.
The surgical management of necrotizing pancreatitis has evolved significantly over the past two decades, with evolution from immediate open surgical necrosectomy for infected pancreatic necrosis to a “step-up” approach with initial percutaneous interventions and delayed formal endoscopic or surgical necrosectomy on an as-needed basis. This has resulted in a substantial reduction in morbidity and mortality in this patient population. The commonly accepted trigger for prompting immediate percutaneous or endoscopic/surgical intervention is the presence of confirmed or strongly suspected infection of the necrotic pancreatic collection, but it was unclear whether a strategy of delaying these interventions would be beneficial or harmful. In the landmark POINTER randomized trial published in NEJM in 20211, 104 patients with infected necrosis were randomized to immediate drainage (within 24 hours) or delayed intervention (until walled-off necrosis was achieved) groups. Interestingly this study found no benefit of immediate intervention, with similar complication and mortality rates between the two groups. However, the delayed intervention group required significantly fewer interventions (mean 2.6 vs 4.4), and 39% responded to antibiotics alone and did not require any invasive intervention. Although these findings supported a delayed intervention strategy, the maximum follow-up was only six months and may not have captured key longer-term outcomes or delayed pancreas-associated complications.
Article 2
Long-Term Outcome of Immediate Versus Postponed Intervention in Patients With Infected Necrotizing Pancreatitis (POINTER): Multicenter Randomized Trial. Van Veldhuisen CL, Sissingh NJ, Boxhoorn L, van Dijk SM, van Grinsven J, Verdonk RC, et al. Ann Surg. 2024 Apr 1;279(4):671-678.
To address this question of the longer-term outcomes, a subsequent analysis of patients from the POINTER trial was recently completed and published.2 This long-term follow up analysis included 88 surviving and 100 total patients from the original POINTER trial, and primarily focused on new events occurring after the initial 6-month follow-up period reported in the original trial. The primary outcome of death and major complications was similar between groups (15% vs 17%, p=0.78) with no difference in the requirement for additional drainage procedures or interventions. Overall, and similar to the original trial results, the delayed group required fewer interventions (median 4 vs 1, p=0001). Among the 15 patients in the delayed group who required no intervention in the original trial, 93% never required an intervention in this analysis. Additional analysis of pancreatic function and quality of life survey scores showed no differences between groups. Taken together, this trial supports a strategy of delayed intervention even in the face of proven or strongly suspected infected pancreatic necrosis and challenges the dogma of immediate intervention in this cohort. However, this requires the caveat that immediate intervention should be performed in the face of clinical deterioration with optimal medical management including antibiotics, resuscitation, and nutritional support. The trial also allowed either endoscopic or surgical drainage procedures, and this choice was not included in the randomization scheme or balanced between groups and thus could have significantly impacted the primary and secondary outcomes. The most important limitation of the POINTER trial is the small sample size which was spread out over a relatively large number of centers (22 participating centers) resulting in underpowering of the study for definitively demonstrating safety and non-inferiority to immediate intervention. In conclusion, these complex patients should be managed by a team and center with experience in necrotizing pancreatitis and with the capabilities for immediate interventional, endoscopic, and surgical intervention, but a strategy of delayed invasive interventions for infected necrosis may be the superior strategy.
Article 3
Impact of Procedure Risk vs Frailty on Outcomes of Elderly Patients Undergoing Emergency General Surgery: Results of a National Analysis. Zakhary B, Coimbra BC, Kwon J, Allison-Aipa T, Firek M, Coimbra R. J Am Coll Surg. 2024 Sep 1;239(3):211-222.
Frailty has become an increasingly prominent topic in recent years. Frail patients undergoing emergency general surgery often experience poor outcomes, however, the impact of procedure risk is frequently overlooked. This study investigated the relationship between procedure risk and frailty in elderly patients undergoing emergency general surgery (EGS).
The NSQIP database was analyzed from 2018 to 2020 to identify older patients who underwent an EGS operation. Patients were categorized using the Modified 5-item Frailty Index and procedure risk. Low-risk procedures included laparoscopic appendectomy, open appendectomy, and laparoscopic cholecystectomy. Open cholecystectomy, open colectomy, laparoscopic colectomy, small bowel resection, perforated ulcer repair, lysis of adhesions, and laparotomy were considered high-risk procedures. Study outcomes included 30-day mortality, complications, failure to rescue, reoperations within 30 days, and unplanned readmissions.
Although both frailty and procedure risk were linked to poorer outcomes, the differences were more pronounced when patients were grouped by procedure risk rather than frailty alone. For example, high-risk procedures were associated with a 3-4 times greater likelihood of reoperations, regardless of patient frailty. Additionally, procedure risk had a significantly stronger effect on mortality odds compared to frailty. This study highlights the critical role of procedure risk in influencing outcomes following emergency general surgery. While frailty remains an important factor, incorporating procedure risk is essential for accurately predicting patient outcomes.
Article 4
To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study. Feather CB, Rehrig S, Allen R, et al. J Trauma Acute Surg. 2024 Jul 1;97(1):73-81.
In this EAST multicenter prospective observational study, the authors aimed to assess the clinical impact of closure technique on clinical outcomes in urgent and emergent nontraumatic colorectal surgery. In total, 557 patients across 15 institutions over a 3 year period (2021-2023) were included. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Statistically significant differences in BMI, race/ethnicity, ASA scores, EBL, ICU admission, vasopressor therapy, procedure details, and wound class were observed across groups. Primary outcomes were surgical site infection (SSI), hospital length of stay (LOS), and in-hospital mortality. After risk adjustment, patients with SLC were at increased risk for superficial SSI (OR, 3.439; p=0.014. Patients with SO were at increased risk for in-hospital mortality when compared to SC (OR, 3.003; p=0.028). There were no significant differences observed in hospital LOS, unplanned return to the OR, or 30-day unplanned readmission.
These results of this study suggest that complete skin closure may be a viable option in EGS patients undergoing colorectal surgery. Furthermore, in a subgroup analysis of SC and SLC, no significant relationships were identified between negative pressure wound vacuum (NPWV) use and SSI, hospital LOS, unplanned return to the OR, home discharge, or 30-day unplanned readmission. This study also highlighted the importance of risk stratification when identifying patients appropriate for SO. In a subgroup analysis of SO, no significant relationships were observed between delayed primary closure (DPC) and SSI, hospital LOS, home discharge, unplanned return to the OR, or 30-day unplanned readmission. Given the multitude of variables that influence the both the choice of closure technique and outcomes, this study lays important groundwork for future randomized controlled trials.
