{"id":8695,"date":"2026-04-07T07:14:50","date_gmt":"2026-04-07T07:14:50","guid":{"rendered":"https:\/\/www.proefschriftmaken.nl\/portfolio\/lotte-boxhoorn\/"},"modified":"2026-04-23T08:39:42","modified_gmt":"2026-04-23T08:39:42","slug":"lotte-boxhoorn","status":"publish","type":"us_portfolio","link":"https:\/\/www.proefschriftmaken.nl\/en\/portfolio\/lotte-boxhoorn\/","title":{"rendered":"Lotte Boxhoorn"},"content":{"rendered":"","protected":false},"excerpt":{"rendered":"","protected":false},"author":8,"featured_media":13763,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"us_portfolio_category":[45],"class_list":["post-8695","us_portfolio","type-us_portfolio","status-publish","has-post-thumbnail","hentry","us_portfolio_category-new-template"],"acf":{"naam_van_het_proefschift":"Multidisciplinary management of severe acute pancreatitis","samenvatting":"Er is geen Nederlandse samenvatting beschikbaar. De Engelse samenvatting vind je <a href=\"https:\/\/www.proefschriftmaken.nl\/en\/portfolio\/lotte-boxhoorn\/\">hier<\/a>.","summary":"The treatment of patients with severe acute pancreatitis has improved considerably over the last few years. Nevertheless, several diagnostic and treatment challenges remain in clinical practice. In my thesis, I address several research questions with the aim to improve treatment of patients with severe acute pancreatitis.\n\nPart I - Evidence-based practice at the start of this thesis\nChapter 2 gives an evidence-based on the diagnosis, classification and treatment of patients with acute pancreatitis based on available literature at the start of my PhD trajectory.\n\nPart II - Timing of the step-up approach\nApproximately 20% of patients suffer from a severe form of acute pancreatitis, characterized by necrosis in and around the pancreas, also known as \u2018necrotizing pancreatitis\u2019. When necrosis becomes infected, this condition is referred to as \u2018infected necrotizing pancreatitis\u2019. Infected necrotizing pancreatitis is treated with a minimally invasive step-up approach. The first step of this approach is catheter drainage, followed by minimally invasive necrosectomy when clinically indicated. Catheter drainage is preferably delayed with antibiotics until the development of encapsulated necrosis. This strategy finds its origin in earlier times when open surgical necrosectomy was performed. However, this is no longer applicable to current medical practice, as minimally invasive drainage procedures are now preferred. As a result, we lack worldwide consensus on the best timing of treatment. Chapter 3 describes the results of the multicenter randomized POINTER trial, in which we investigated this issue. The results demonstrate that drainage directly after diagnosing infected necrosis (\u2018immediate drainage approach\u2019) did not lead to lower mortality or complication rates. However, when the intervention was postponed (\u2018postponed drainage approach\u2019), less interventions for infected necrosis were required and more than one-third of patients were successfully treated with antibiotics only.\n\nPart III - The endoscopic step-up approach\nWe know from previous literature (TENSION trial) that clinical outcomes of patients with infected necrotizing pancreatitis treated with an endoscopic step-up approach are similar to those treated with a surgical step-up approach. The endoscopic step-up approach was, however, associated with two important advantages; a shorter hospital stay and the development of fewer pancreaticocutaneous fistulas. For this reason, the endoscopic step-up approach is nowadays preferred. Consequently, a new stent was recently invented to improve endoscopic drainage of infected necrosis: the lumen-apposing metal stent (LAMS). The LAMS has been increasingly used, but its superiority over the standard double-pigtail plastic stents is not yet proven. In addition, LAMS are more expensive and have been associated with complications, in particular severe bleeding. Chapter 4 describes the results of the prospective multicenter AXIOMA study, in which we investigated the use of LAMS for endoscopic drainage and compared the results to the TENSION trial in which plastic stents were used. The results demonstrated no differences in clinical outcomes of patients treated with LAMS or plastic stents. However, in contrast to current literature reports, the use of LAMS did not lead to higher complication rates or healthcare related costs.\n\nAlthough the endoscopic step-up approach has important short-term benefits, the long-term clinical outcomes are unknown. Chapter 5 addresses the results of the ExTENSION study. In this study, we investigated the long-term clinical outcomes of patients who participated in the TENSION trial. The results showed that patients treated with endoscopy suffered from fewer pancreaticocutaneous fistulas and need fewer re-interventions during long-term follow-up in comparison to patients that were treated surgically. Another important finding was that a considerable number of patients still developed endocrine or exocrine pancreatic insufficiency during long-term follow-up.\n\nPancreatic and peripancreatic necrosis can become infected, but usually remains sterile. If sterile necrotic collections do not resolve spontaneously, it can cause symptoms such as pain, trouble eating, or biliary obstruction. Drainage should be considered if symptoms persist, but with the inherent risk of iatrogenic infection. It is currently unknown how many patients will be affected by iatrogenic infection after endoscopic drainage. Chapter 6 describes a retrospective case series on patients that were drained endoscopically for ongoing symptoms related to sterile necrosis. The results demonstrated that nearly three-quarters of patients developed iatrogenic infection post-drainage, and therefore required multiple re-interventions. Eventually, the majority of patients did fully recover during follow-up.\n\nPart IV - Disruption of disconnection of the pancreatic duct\nPancreatic duct leaks can occur as a result or pancreas parenchyma necrosis. This phenomenon is also known as a partial pancreatic duct disruption or a complete pancreatic duct disconnection. Damage to the pancreatic ductal system can lead to several complications, such as recurrent pancreatic fluid collections or pancreatic fistulas. Treatment guidelines or experts recommendations on this complication do currently not exist. We therefore conducted an international expert survey with case descriptions. The results of this survey are summarized in Chapter 7. We found that most experts advise a MRCP to diagnose a pancreatic duct disruption or disconnection. There was, however, a lack of general agreement among experts about the preferred treatment strategy. However, the experts favored endoscopic drainage over other treatment modalities in patients with infected necrosis and coexistent pancreatic duct disruption or disconnection.\n\nPart V - Acute pancreatitis and COVID-19\nCoronavirus disease 2019 (COVID-19) has caused an enormous global impact on our healthcare system. At the beginning of the pandemic, several literature reports informed us about a possible relation between COVID-19 and acute pancreatitis. However, most research was of low quality and different definitions of acute pancreatitis were used. For this reason, we wanted to investigate the relation between COVID-19 and acute pancreatitis. Chapter 8 describes a cross-sectional study in which we evaluated how many admitted patients with COVID-19 developed acute pancreatitis according to the revised Atlanta criteria. We also evaluated whether acute pancreatitis could have been induced by COVID-19 infection. We found that only 1% of patients with COVID-19 had acute pancreatitis without a known cause, and might have been be related to COVID-19. None of these patients developed necrotizing pancreatitis, but did suffer from severe symptoms of the COVID-19 infection, such as organ failure. For this reason, we hypothesized that the patients developed acute pancreatitis due to pancreatic hypoperfusion, associated with the severe COVID-19 infection. Future research could usefully explore this hypothesis and would be of great help in determining the relation between acute pancreatitis and COVID-19.","auteur":"Lotte Boxhoorn","auteur_slug":"lotte-boxhoorn","publicatiedatum":"25 maart 2022","taal":"NL","url_flipbook":"https:\/\/ebook.proefschriftmaken.nl\/ebook\/lotteboxhoorn?iframe=true","url_download_pdf":"","url_epub":"","ordernummer":"FTP-202604070710","isbn":"978-94-6423-673-6","doi_nummer":"","naam_universiteit":"Universiteit van Amsterdam","afbeeldingen":13763,"naam_student:":"","binnenwerk":"","universiteit":"Universiteit van Amsterdam","cover":"","afwerking":"","cover_afwerking":"","design":""},"_links":{"self":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/8695","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio"}],"about":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/types\/us_portfolio"}],"author":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/users\/8"}],"replies":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/comments?post=8695"}],"version-history":[{"count":1,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/8695\/revisions"}],"predecessor-version":[{"id":8696,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio\/8695\/revisions\/8696"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media\/13763"}],"wp:attachment":[{"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/media?parent=8695"}],"wp:term":[{"taxonomy":"us_portfolio_category","embeddable":true,"href":"https:\/\/www.proefschriftmaken.nl\/en\/wp-json\/wp\/v2\/us_portfolio_category?post=8695"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}