Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step Up Approach: Comparison to a Modern Open Necrosectomy Cohort
Casey M. Luckhurst1, Majed El Hechi1 ,Ahmed E. Elsharkawy1, Ahmed I. Eid1, Lydia M. Maurer1, Haytham M. Kaafarani1, Ashraf Thabet2, David G. Forcione3, Carlos Fernandez-Del Castillo1, Keith D. Lillemoe1, Peter J. Fagenholz1
1Massachusetts General Hospital Department of Surgery, Boston, MA; 2Massachusetts General Hospital Department of Interventional Radiology, Boston, MA; 3Massachusetts General Hospital Department of Gastroenterology, Boston, MA
Background: A minimally invasive step-up (MIS) approach has been associated with reduced morbidity compared to open surgical necrosectomy (OSN) for treatment of necrotizing pancreatitis (NP). We sought to determine if transitioning from an OSN to an MIS-based approach would result in reduced mortality. MIS interventions included percutaneous drainage (PD), endoscopic transgastric necrosectomy (ETN), video-assisted retroperitoneal debridement (VARD), sinus tract endoscopic necrosectomy (STE), or a combination of techniques, with selective use of OSN.
Methods: Observational cohort study with retrospective comparison at a single tertiary referral center (2006-2019). 88 patients were treated with OSN and 92 were treated with a MIS-based approach. Baseline characteristics and clinical outcomes were compared between groups. The primary outcome was mortality.
Results: There was no difference in baseline characteristics. One-year mortality was 3% with MIS compared to 15% with OSN (p=0.012). Additionally, organ failure was higher with OSN (45% vs 29%, p=0.025), but there were higher bleeding rates with MIS (22% vs 9%) (p=0.014). In the MIS group, 9% were treated with PD, 32% with ETN, 8% with VARD, 15% with STE, and 33% with a combination of techniques.
Conclusion: Adoption of a multidisciplinary MIS-based approach to NP resulted in a 6-fold decrease in mortality compared to OSN.
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