Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step-Up Approach: Comparison with a Modern Open Necrosectomy Cohort

• Published in: Journal of the American College of Surgeons Vol. 230; no. 6; pp. 873 - 883
• Main Authors: Luckhurst, Casey M., El Hechi, Majed, Elsharkawy, Ahmed E., Eid, Ahmed I., Maurer, Lydia R., Kaafarani, Haytham M., Thabet, Ashraf, Forcione, David G., Fernández-Del Castillo, Carlos, Lillemoe, Keith D., Fagenholz, Peter J.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.06.2020
• Subjects: Adult; Aged; Cohort Studies; Critical Care; Debridement - adverse effects; Debridement - methods; Drainage - adverse effects; Drainage - methods; Endoscopy - adverse effects; Endoscopy - methods; Female; Humans; Length of Stay; Male; Middle Aged; Pancreatitis, Acute Necrotizing - etiology; Pancreatitis, Acute Necrotizing - mortality; Pancreatitis, Acute Necrotizing - surgery; Postoperative Complications - epidemiology; Survival Rate; Treatment Outcome; LOS; NP; STE; VARD; MIS; OSN; ETN
• ISSN: 1072-7515; 1879-1190
• DOI: 10.1016/j.jamcollsurg.2020.01.038

A minimally invasive step-up (MIS) approach has been associated with reduced morbidity compared with open surgical necrosectomy (OSN) for treatment of necrotizing pancreatitis. We sought to determine whether transitioning from an OSN to an MIS-based approach would result in reduced mortality. MIS interventions included percutaneous drainage, endoscopic transgastric necrosectomy, video-assisted retroperitoneal debridement, sinus tract endoscopic necrosectomy, or a combination of techniques, with selective use of OSN. We conducted an observational cohort study with retrospective comparison at a single tertiary referral center (2006 through 2019). Eighty-eight patients were treated with OSN and 91 were treated with an MIS-based approach. Baseline characteristics and clinical outcomes were compared between groups. The primary end point was 90-day mortality. There was no difference in baseline characteristics. Ninety-day mortality was 2% with MIS compared with 10% with OSN (p = 0.03). One-year mortality was 3% with MIS compared with 15% with OSN (p = 0.012). The rate of organ failure was lower with MIS (30% vs 45%; p = 0.029), but there was a higher bleeding rate (19% vs 9%; p = 0.064). In the MIS group, 9% were treated with percutaneous drainage, 32% with endoscopic transgastric necrosectomy, 8% with video-assisted retroperitoneal debridement, 15% with sinus tract endoscopic necrosectomy, and 27% with a combination of techniques. Adoption of a multidisciplinary MIS-based approach to necrotizing pancreatitis resulted in a 5-fold decrease in mortality compared with OSN. [Display omitted]