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Hollemans RA, Bakker OJ, Boermeester MA, Bollen TL, Bosscha K, Bruno MJ, Buskens E, Dejong CH, van Duijvendijk P, van Eijck CH, Fockens P, van Goor H, van Grevenstein WM, van der Harst E, Heisterkamp J, Hesselink EJ, Hofker S, Houdijk AP, Karsten T, Kruyt PM, van Laarhoven CJ, Laméris JS, van Leeuwen MS, Manusama ER, Molenaar IQ, Nieuwenhuijs VB, van Ramshorst B, Roos D, Rosman C, Schaapherder AF, van der Schelling GP, Timmer R, Verdonk RC, de Wit RJ, Gooszen HG, Besselink MG, van Santvoort HC. Superiority of Step-up Approach vs Open Necrosectomy in Long-term Follow-up of Patients With Necrotizing Pancreatitis. Gastroenterology 2019; 156:1016-1026. [PMID: 30391468 DOI: 10.1053/j.gastro.2018.10.045] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/10/2018] [Accepted: 10/27/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS In a 2010 randomized trial (the PANTER trial), a surgical step-up approach for infected necrotizing pancreatitis was found to reduce the composite endpoint of death or major complications compared with open necrosectomy; 35% of patients were successfully treated with simple catheter drainage only. There is concern, however, that minimally invasive treatment increases the need for reinterventions for residual peripancreatic necrotic collections and other complications during the long term. We therefore performed a long-term follow-up study. METHODS We reevaluated all the 73 patients (of the 88 patients randomly assigned to groups) who were still alive after the index admission, at a mean 86 months (±11 months) of follow-up. We collected data on all clinical and health care resource utilization endpoints through this follow-up period. The primary endpoint was death or major complications (the same as for the PANTER trial). We also measured exocrine insufficiency, quality of life (using the Short Form-36 and EuroQol 5 dimensions forms), and Izbicki pain scores. RESULTS From index admission to long-term follow-up, 19 patients (44%) died or had major complications in the step-up group compared with 33 patients (73%) in the open-necrosectomy group (P = .005). Significantly lower proportions of patients in the step-up group had incisional hernias (23% vs 53%; P = .004), pancreatic exocrine insufficiency (29% vs 56%; P = .03), or endocrine insufficiency (40% vs 64%; P = .05). There were no significant differences between groups in proportions of patients requiring additional drainage procedures (11% vs 13%; P = .99) or pancreatic surgery (11% vs 5%; P = .43), or in recurrent acute pancreatitis, chronic pancreatitis, Izbicki pain scores, or medical costs. Quality of life increased during follow-up without a significant difference between groups. CONCLUSIONS In an analysis of long-term outcomes of trial participants, we found the step-up approach for necrotizing pancreatitis to be superior to open necrosectomy, without increased risk of reinterventions.
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Affiliation(s)
- Robbert A Hollemans
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Olaf J Bakker
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Erik Buskens
- Department of Epidemiology, University Medical Center Groningen, and Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands
| | - Cornelis H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands and Department of Surgery, Universitätsklinikum Aachen, Aachen, Germany
| | | | - Casper H van Eijck
- Deptartment of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | - Joos Heisterkamp
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Eric J Hesselink
- Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
| | - Sijbrand Hofker
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Tom Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Philip M Kruyt
- Department of Surgery, Hospital Gelderse Vallei, Ede, the Netherlands
| | | | - Johan S Laméris
- Department of Radiology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Maarten S van Leeuwen
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Eric R Manusama
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Bert van Ramshorst
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | | | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Ralph J de Wit
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - Hein G Gooszen
- Department of Operating Rooms-Evidence Based Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands.
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2
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Rovers KP, Simkens GA, Vissers PA, Lemmens VE, Verwaal VJ, Bremers AJ, Wiezer MJ, Burger JW, Hemmer PH, Boot H, van Grevenstein WM, Meijerink WJ, Aalbers AG, Punt CJ, Tanis PJ, de Hingh IH. Survival of patients with colorectal peritoneal metastases is affected by treatment disparities among hospitals of diagnosis: A nationwide population-based study. Eur J Cancer 2017; 75:132-140. [PMID: 28222307 DOI: 10.1016/j.ejca.2016.12.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/24/2016] [Accepted: 12/11/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the Netherlands, surgery for peritoneal metastases of colorectal cancer (PMCRC) is centralised, whereas PMCRC is diagnosed in all hospitals. This study assessed whether hospital of diagnosis affects treatment selection and overall survival (OS). METHODS Between 2005 and 2015, all patients with synchronous PMCRC without systemic metastases were selected from the Netherlands Cancer Registry. Treatment was classified as cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), systemic therapy or other/no treatment. Hospitals of diagnosis were classified as: (1) non-teaching or academic/teaching hospital and (2) HIPEC centre or referring hospital. Referring hospitals were further classified based on the frequency of CRS/HIPEC as high-, medium- or low-frequency hospital. Multivariable regression analyses were used to assess the independent influence of hospital categories on the likelihood of CRS/HIPEC and OS. RESULTS A total of 2661 patients, diagnosed in 89 hospitals, were included. At individual hospital level, CRS/HIPEC and systemic therapy ranged from 0% to 50% and 6% to 67%, respectively. Hospital of diagnosis influenced the likelihood of CRS/HIPEC: 33% versus 13% for HIPEC centres versus referring hospitals (odds ratio (OR) 3.66 [2.40-5.58]) and 11% versus 17% for non-teaching hospitals versus academic/teaching hospitals (OR 0.60 [0.47-0.77]). Hospital of diagnosis affected median OS: 14.1 versus 9.6 months for HIPEC centres versus referring hospitals (hazard ratio (HR) 0.82 [0.67-0.99]) and 8.7 versus 11.5 months for non-teaching hospitals versus academic/teaching hospitals (HR 1.15 [1.06-1.26]). Compared with diagnosis in medium-frequency referring hospitals, median OS was increased in high-frequency referring hospitals (12.6 months, HR 0.82 [0.73-0.91]) and reduced in low-frequency referring hospitals (8.1 months, HR 1.12 [1.01-1.24]). CONCLUSION Treatment disparities among hospitals of diagnosis and their impact on survival indicate suboptimal treatment selection for PMCRC.
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Affiliation(s)
- Koen P Rovers
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands
| | - Geert A Simkens
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands
| | - Pauline A Vissers
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), PO Box 19079, 3501 DB, Utrecht, The Netherlands
| | - Valery E Lemmens
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), PO Box 19079, 3501 DB, Utrecht, The Netherlands; Department of Public Health, Erasmus Medical Centre, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Victor J Verwaal
- Department of Surgery, Aarhus University Hospital, Norrebrogade 44, DK-8000, Aarhus, Denmark
| | - Andre J Bremers
- Department of Surgery, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, Sint Antonius Hospital, PO Box 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Jacobus W Burger
- Department of Surgery, Erasmus Medical Centre, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Patrick H Hemmer
- Department of Surgery, University Medical Centre Groningen, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Henk Boot
- Department of Gastroenterology and Hepatology, Antoni van Leeuwenhoek Hospital, PO Box 90203, 1006 BE, Amsterdam, The Netherlands
| | | | - Wilhelmus J Meijerink
- Department of Surgery, VU University Medical Centre, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Arend G Aalbers
- Department of Surgery, Antoni van Leeuwenhoek Hospital, PO Box 90203, 1006 BE, Amsterdam, The Netherlands
| | - Cornelis J Punt
- Department of Medical Oncology, Academic Medical Centre, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands.
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3
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Vennix S, Musters GD, Mulder IM, Swank HA, Consten EC, Belgers EH, van Geloven AA, Gerhards MF, Govaert MJ, van Grevenstein WM, Hoofwijk AG, Kruyt PM, Nienhuijs SW, Boermeester MA, Vermeulen J, van Dieren S, Lange JF, Bemelman WA. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet 2015. [PMID: 26209030 DOI: 10.1016/s0140-6736(15)61168-0] [Citation(s) in RCA: 165] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Case series suggest that laparoscopic peritoneal lavage might be a promising alternative to sigmoidectomy in patients with perforated diverticulitis. We aimed to assess the superiority of laparoscopic lavage compared with sigmoidectomy in patients with purulent perforated diverticulitis, with respect to overall long-term morbidity and mortality. METHODS We did a multicentre, parallel-group, randomised, open-label trial in 34 teaching hospitals and eight academic hospitals in Belgium, Italy, and the Netherlands (the Ladies trial). The Ladies trial is split into two groups: the LOLA group comparing laparoscopic lavage with sigmoidectomy and the DIVA group comparing Hartmann's procedure with sigmoidectomy plus primary anastomosis. The DIVA section of this trial is still underway but here we report the results of the LOLA section. Patients with purulent perforated diverticulitis were enrolled for LOLA, excluding patients with faecal peritonitis, aged older than 85 years, with high-dose steroid use (≥20 mg daily), and haemodynamic instability. Patients were randomly assigned (2:1:1; stratified by age [<60 years vs ≥60 years]) using secure online computer randomisation to laparoscopic lavage, Hartmann's procedure, or primary anastomosis in a parallel design after diagnostic laparoscopy. Patients were analysed according to a modified intention-to-treat principle and were followed up after the index operation at least once in the outpatient setting and after sigmoidoscopy and stoma reversal, according to local protocols. The primary endpoint was a composite endpoint of major morbidity and mortality within 12 months. This trial is registered with ClinicalTrials.gov, number NCT01317485. FINDINGS Between July 1, 2010, and Feb 22, 2013, 90 patients were randomly assigned in the LOLA section of the Ladies trial when the study was terminated by the data and safety monitoring board because of an increased event rate in the lavage group. Two patients were excluded for protocol violations. The primary endpoint occurred in 30 (67%) of 45 patients in the lavage group and 25 (60%) of 42 patients in the sigmoidectomy group (odds ratio 1·28, 95% CI 0·54-3·03, p=0·58). By 12 months, four patients had died after lavage and six patients had died after sigmoidectomy (p=0·43). INTERPRETATION Laparoscopic lavage is not superior to sigmoidectomy for the treatment of purulent perforated diverticulitis. FUNDING Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Sandra Vennix
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands; Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Irene M Mulder
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hilko A Swank
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Esther C Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands
| | - Eric H Belgers
- Department of Surgery, Atrium Medical Centre, Heerlen, Netherlands
| | | | | | - Marc J Govaert
- Department of Surgery, Westfriesgasthuis, Hoorn, Netherlands
| | | | - Anton G Hoofwijk
- Department of Surgery, Orbis Medical Centre, Sittard, Netherlands
| | - Philip M Kruyt
- Department of Surgery, Gelderse Vallei Hospital, Ede, Netherlands
| | | | | | | | - Susan van Dieren
- Clinical Research Unit, Academic Medical Center, Amsterdam, Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands.
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4
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Vennix S, Musters GD, Mulder IM, Swank HA, Consten EC, Belgers EH, van Geloven AA, Gerhards MF, Govaert MJ, van Grevenstein WM, Hoofwijk AG, Kruyt PM, Nienhuijs SW, Boermeester MA, Vermeulen J, van Dieren S, Lange JF, Bemelman WA. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet 2015. [PMID: 26209030 DOI: 10.1016/s0140-6736(15)] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Case series suggest that laparoscopic peritoneal lavage might be a promising alternative to sigmoidectomy in patients with perforated diverticulitis. We aimed to assess the superiority of laparoscopic lavage compared with sigmoidectomy in patients with purulent perforated diverticulitis, with respect to overall long-term morbidity and mortality. METHODS We did a multicentre, parallel-group, randomised, open-label trial in 34 teaching hospitals and eight academic hospitals in Belgium, Italy, and the Netherlands (the Ladies trial). The Ladies trial is split into two groups: the LOLA group comparing laparoscopic lavage with sigmoidectomy and the DIVA group comparing Hartmann's procedure with sigmoidectomy plus primary anastomosis. The DIVA section of this trial is still underway but here we report the results of the LOLA section. Patients with purulent perforated diverticulitis were enrolled for LOLA, excluding patients with faecal peritonitis, aged older than 85 years, with high-dose steroid use (≥20 mg daily), and haemodynamic instability. Patients were randomly assigned (2:1:1; stratified by age [<60 years vs ≥60 years]) using secure online computer randomisation to laparoscopic lavage, Hartmann's procedure, or primary anastomosis in a parallel design after diagnostic laparoscopy. Patients were analysed according to a modified intention-to-treat principle and were followed up after the index operation at least once in the outpatient setting and after sigmoidoscopy and stoma reversal, according to local protocols. The primary endpoint was a composite endpoint of major morbidity and mortality within 12 months. This trial is registered with ClinicalTrials.gov, number NCT01317485. FINDINGS Between July 1, 2010, and Feb 22, 2013, 90 patients were randomly assigned in the LOLA section of the Ladies trial when the study was terminated by the data and safety monitoring board because of an increased event rate in the lavage group. Two patients were excluded for protocol violations. The primary endpoint occurred in 30 (67%) of 45 patients in the lavage group and 25 (60%) of 42 patients in the sigmoidectomy group (odds ratio 1·28, 95% CI 0·54-3·03, p=0·58). By 12 months, four patients had died after lavage and six patients had died after sigmoidectomy (p=0·43). INTERPRETATION Laparoscopic lavage is not superior to sigmoidectomy for the treatment of purulent perforated diverticulitis. FUNDING Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Sandra Vennix
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands; Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Irene M Mulder
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Hilko A Swank
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Esther C Consten
- Department of Surgery, Meander Medical Centre, Amersfoort, Netherlands
| | - Eric H Belgers
- Department of Surgery, Atrium Medical Centre, Heerlen, Netherlands
| | | | | | - Marc J Govaert
- Department of Surgery, Westfriesgasthuis, Hoorn, Netherlands
| | | | - Anton G Hoofwijk
- Department of Surgery, Orbis Medical Centre, Sittard, Netherlands
| | - Philip M Kruyt
- Department of Surgery, Gelderse Vallei Hospital, Ede, Netherlands
| | | | | | | | - Susan van Dieren
- Clinical Research Unit, Academic Medical Center, Amsterdam, Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, Netherlands.
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5
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Bakker OJ, van Brunschot S, van Santvoort HC, Besselink MG, Bollen TL, Boermeester MA, Dejong CH, van Goor H, Bosscha K, Ahmed Ali U, Bouwense S, van Grevenstein WM, Heisterkamp J, Houdijk AP, Jansen JM, Karsten TM, Manusama ER, Nieuwenhuijs VB, Schaapherder AF, van der Schelling GP, Schwartz MP, Spanier BWM, Tan A, Vecht J, Weusten BL, Witteman BJ, Akkermans LM, Bruno MJ, Dijkgraaf MG, van Ramshorst B, Gooszen HG. Early versus on-demand nasoenteric tube feeding in acute pancreatitis. N Engl J Med 2014; 371:1983-93. [PMID: 25409371 DOI: 10.1056/nejmoa1404393] [Citation(s) in RCA: 175] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Early enteral feeding through a nasoenteric feeding tube is often used in patients with severe acute pancreatitis to prevent gut-derived infections, but evidence to support this strategy is limited. We conducted a multicenter, randomized trial comparing early nasoenteric tube feeding with an oral diet at 72 hours after presentation to the emergency department in patients with acute pancreatitis. METHODS We enrolled patients with acute pancreatitis who were at high risk for complications on the basis of an Acute Physiology and Chronic Health Evaluation II score of 8 or higher (on a scale of 0 to 71, with higher scores indicating more severe disease), an Imrie or modified Glasgow score of 3 or higher (on a scale of 0 to 8, with higher scores indicating more severe disease), or a serum C-reactive protein level of more than 150 mg per liter. Patients were randomly assigned to nasoenteric tube feeding within 24 hours after randomization (early group) or to an oral diet initiated 72 hours after presentation (on-demand group), with tube feeding provided if the oral diet was not tolerated. The primary end point was a composite of major infection (infected pancreatic necrosis, bacteremia, or pneumonia) or death during 6 months of follow-up. RESULTS A total of 208 patients were enrolled at 19 Dutch hospitals. The primary end point occurred in 30 of 101 patients (30%) in the early group and in 28 of 104 (27%) in the on-demand group (risk ratio, 1.07; 95% confidence interval, 0.79 to 1.44; P=0.76). There were no significant differences between the early group and the on-demand group in the rate of major infection (25% and 26%, respectively; P=0.87) or death (11% and 7%, respectively; P=0.33). In the on-demand group, 72 patients (69%) tolerated an oral diet and did not require tube feeding. CONCLUSIONS This trial did not show the superiority of early nasoenteric tube feeding, as compared with an oral diet after 72 hours, in reducing the rate of infection or death in patients with acute pancreatitis at high risk for complications. (Funded by the Netherlands Organization for Health Research and Development and others; PYTHON Current Controlled Trials number, ISRCTN18170985.).
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Affiliation(s)
- Olaf J Bakker
- The authors' affiliations are listed in the Appendix
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