Endoscopic Versus Surgical Step-Up Approach for Infected Necrotizing Pancreatitis (ExTENSION):Long-term Follow-up of a Randomized Trial

Background & Aims: Previous randomized trials, including the Transluminal Endoscopic Step-Up Approach Versus Minimally Invasive Surgical Step-Up Approach in Patients With Infected Pancreatic Necrosis (TENSION) trial, demonstrated that the endoscopic step-up approach might be preferred over the surgical step-up approach in patients with infected necrotizing pancreatitis based on favorable short-term outcomes. We compared long-term clinical outcomes of both step-up approaches after a period of at least 5 years. Methods: In this long-term follow-up study, we reevaluated all clinical data on 83 patients (of the originally 98 included patients) from the TENSION trial who were still alive after the initial 6-month follow-up. The primary end point, similar to the TENSION trial, was a composite of death and major complications. Secondary end points included individual major complications, pancreaticocutaneous fistula, reinterventions, pancreatic insufficiency, and quality of life. Results: After a mean follow-up period of 7 years, the primary end point occurred in 27 patients (53%) in the endoscopy group and in 27 patients (57%) in the surgery group (risk ratio [RR], 0.93; 95% confidence interval [CI], 0.65–1.32; P = .688). Fewer pancreaticocutaneous fistulas were identified in the endoscopy group (8% vs 34%; RR, 0.23; 95% CI, 0.08–0.83). After the initial 6-month follow-up, the endoscopy group needed fewer reinterventions than the surgery group (7% vs 24%; RR, 0.29; 95% CI, 0.09–0.99). Pancreatic insufficiency and quality of life did not differ between groups. Conclusions: At long-term follow-up, the endoscopic step-up approach was not superior to the surgical step-up approach in reducing death or major complications in patients with infected necrotizing pancreatitis. However, patients assigned to the endoscopic approach developed overall fewer pancreaticocutaneous fistulas and needed fewer reinterventions after the initial 6-month follow-up. Netherlands Trial Register no: NL8571

Small bowel transplantation in rats:The effect of pretransplant donor-specific blood transfusions on various segments of small bowel grafts

The effects of pretransplant donor-specific blood transfusion on the survival of orthotopic small bowel transplants in rats were investigated in the fully allogeneic BN (Rtln) to WAG (Rtlu) donor-host combination. Previous studies show that in this combination DSTs lead to permanent survival of heterotopically transplanted hearts, marked prolongation of kidney grafts, and moderate prolongation of pancreas grafts but have no effect on skin grafts. Without pretreatment, total small bowel grafts (±45 cm) were rejected in 12.2 ± 1.8 days (mean ± SD), and 10-cm segments of jejunum or ileum in 11.2 ± 4.0 and 11.6 ± 0.5 days, respectively. Three DSTs given on days -21, -14, and -7 before transplantation had no effect on graft survival in any of the groups tested. Total small bowel grafts were rejected in 12.8 ± 2.5 days, and 10- cm-long segments of jejunum or ileum in 17.0 ± 7.2 days and 11.5 ± 2.7 days, respectively. Graft-versus-host disease, which was mild and transient, occurred in 50% of the nontreated rats engrafted with a total small bowel, in 40% of the animals transplanted with an ileum segment, and in none of the rats that received a jejunal transplant. In the DST-pretreated groups, none of the animals transplanted witih a total small bowel or ileum segment and 16.6% of the animals transplanted with a jejunum segment showed clinical signs of GVHD. When DST pretreatment was combined with cyclosporine, grafts did not survive any longer than with cyclosporine treatment alone. It is concluded that DSTs ameliorate GVHD but do not prolong the survival of small bowel allografts nor act additively with cyclosporine treatment.</p