Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial.

Kumar M, Patil NS, Mohapatra N, Sindwani G, Dhingra U, Yadav A et al.
Ann Surg 2024; 279: 932-944.

A temporary shunt reduced intra-operative blood loss (P=0.004) and need for transfusion in this study of 60 procedures. The shunted patients were also more haemodynamically stable in the anhepatic phase, requiring less vasopressor support, with better postoperative renal function. There were no other differences in postoperative outcomes.

Comment: The observed advantages should improve outcomes, but perhaps the study was too small to be definitive.

Labori KJ, Bratlie SO, Andersson B, Angelsen J-H, Biorserud C, Bjornsson B et al, for the Nordic Pancreatic Cancer Trial-1 study group.

Lancet Gastrohepatol 2024; 9: 205-217.

Survival after 18 months was not improved after neoadjuvant chemotherapy (73 per cent, versus 60 per cent in controls, P=0.050) in this study that included 140 patients.

Comment: Negative result here, but more data for a larger meta-analysis.

Welsch T, Müssle B, Korn S, Sturm D, Bork U.
Br J Surgery 2022; 109: 37-45.

A total of 445 procedures were included. In the intention to treat analysis, there was no significant reduction in haemorrhage (2.9 versus 7.1 per cent, odds ratio 0.39, 95 per cent confidence interval 0.15 to 1.02, P=0.071). In the per protocol analysis the effect was more positive: odds ratio 0.26, 0.09 to 0.8, P=0.017.

Comment: The authors reasonably conclude falciform wrap should be considered during pancreaticoduodenectomy.