Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step-Up Approach: Comparison with a Modern Open Necrosectomy Cohort - 22/05/20

Doi : 10.1016/j.jamcollsurg.2020.01.038

Casey M. Luckhurst, MD ^a, Majed El Hechi, MD ^a, Ahmed E. Elsharkawy, MD ^a, Ahmed I. Eid, MD ^a, Lydia R. Maurer, MD ^a, Haytham M. Kaafarani, MD, MPH, FACS ^a, Ashraf Thabet, MD ^b, David G. Forcione, MD ^c,^d, Carlos Fernández-Del Castillo, MD, FACS ^a, Keith D. Lillemoe, MD, FACS ^a, Peter J. Fagenholz, MD, FACS ^a,^⁎
^a Department of Surgery, Massachusetts General Hospital Boston, MA
^b Department of Radiology, Massachusetts General Hospital Boston, MA
^c Department of Gastroenterology, Massachusetts General Hospital Boston, MA
^d Department of Gastroenterology, Boca Raton Regional Hospital, Boca Raton, FL

^∗Correspondence address: Peter J Fagenholz, MD, FACS, Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, 165 Cambridge St, Suite 810, Boston, MA 02114.Department of SurgeryDivision of TraumaEmergency Surgery, and Surgical Critical CareMassachusetts General Hospital165 Cambridge St, Suite 810BostonMA02114

Abstract

Background

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.

Study Design

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.

Results

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.

Conclusions

Adoption of a multidisciplinary MIS-based approach to necrotizing pancreatitis resulted in a 5-fold decrease in mortality compared with OSN.

Le texte complet de cet article est disponible en PDF.

Visual Abstract

Le texte complet de cet article est disponible en PDF.

Abbreviations and Acronyms : ETN, LOS, MIS, NP, OSN, STE, VARD

Plan

Preoperative characteristics

Interventions

Postoperative outcomes

Discussion

Conclusions

Author Contributions

	CME questions for this article available at jacscme.facs.org
	Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Ronald J Weigel, CME Editor, has nothing to disclose.