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The PANTER randomized trial compared a minimally invasive step-up strategy with primary open necrosectomy for patients with infected or suspected infected necrotizing pancreatitis. Instead of proceeding directly to a large open operation, the step-up approach began with percutaneous or endoscopic drainage, followed by minimally invasive necrosectomy only when necessary. The strategy reduced the burden of major complications and established a new treatment philosophy for severe necrotizing pancreatitis: control sepsis with the least invasive intervention that is effective, and escalate only when required. The study had a major influence on HPB and critical-care practice because it demonstrated that more aggressive surgery is not necessarily better. For surgical teams, the practical message is that timing, source control, organ support and multidisciplinary coordination are as important as the operative technique itself. Not every patient requires necrosectomy, and when intervention is needed, a staged approach can limit physiologic stress. The findings underpin contemporary “step-up” pathways used in specialized pancreatic centers.
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The PANTER randomized trial compared a minimally invasive step-up strategy with primary open necrosectomy for patients with infected or suspected infected necrotizing pancreatitis. Instead of proceeding directly to a large open operation, the step-up approach began with percutaneous or endoscopic drainage, followed by minimally invasive necrosectomy only when necessary. The strategy reduced the burden of major complications and established a new treatment philosophy for severe necrotizing pancreatitis: control sepsis with the least invasive intervention that is effective, and escalate only when required. The study had a major influence on HPB and critical-care practice because it demonstrated that more aggressive surgery is not necessarily better. For surgical teams, the practical message is that timing, source control, organ support and multidisciplinary coordination are as important as the operative technique itself. Not every patient requires necrosectomy, and when intervention is needed, a staged approach can limit physiologic stress. The findings underpin contemporary “step-up” pathways used in specialized pancreatic centers.
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