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Minimally Invasive Surgical Cystgastrostomy and Necrosectomy for the Management of Walled off Pancreatic Necrosis; Comparison With Endoscopic Approach At a High Volume Pancreatic Center
Mohammad Khreiss*1, Georgios Papachristou2, Mustapha Daouadi1, Mazen Zenati1, Kenneth Lee1, Melissa E. Hogg1, ADAM Slivka2, Jennifer Chennat2, Andres Gelrud3, Herbert Zeh1, Amer H. Zureikat1
1Department of Surgery, UPMC, Pittsburgh, PA; 2Gastroenterology, UPMC, Pittsburgh, PA; 3Gastroenterology, University of Chicago, Chicago, IL
Introduction: Walled off pancreatic necrosis (WOPN) is a potentially lethal complication of acute necrotic pancreatitis occurring in 5-10% of patients. We hypothesized that minimally invasive surgical cystgastrostomy and necrosectomy is a safe and feasible approach with comparable results to endoscopic management.
Method: A retrospective review of a prospectively maintained data base of patients who underwent minimally invasive surgical (laparoscopic and robotic) cystgastrostomy and necrosectomy for WOPN was compared to a retrospective cohort of patients who underwent endoscopic cystgastrostomy and necrosectomy. Periprocedural outcomes were analyzed. Failure for the surgical group was defined as the need for any reintervention due to persistence of WOPN, whereas it was defined as the need for surgery in the endoscopic group.
Results: Between 2008 and 2013, 15 patients underwent minimally invasive necrosectomy (robotic =10, laparoscopic=5) and 22 patients underwent endoscopic cystgastrosotomy and necrosectomy. The surgical cohort had a larger median cyst size compared to the endoscopic group (16 cm vs 12 cm P=0.03). There were no differences in age, sex, race, BMI, Charlson Comorbidity Index (CCI), etiology of pancreatitis, and location of WOPN between both groups (all P=NS). For the surgical cohort, average OR time was 195 min, average EBL was 67 cc and 60% underwent concomitant cholecystectomy for biliary etiology. There was no mortality in either group and no statistical difference in the frequency of post procedural complications; surgical group (pulmonary embolus(1);splenic artery pseudoaneurysm (1), infected collection (2)) and endotherapy group (perforation (1), bleeding (1),infected collection (2)). Failure of WOPN to resolve occurred in 3 patients (20%) in the surgical group compared to 3 patients (13.6%) in the endoscopic group (P=0.66). Reintervention was less common in the surgical group versus the endotherapy (20% versus 59%, P= 0.041) with a median re-intervention rate of 0 (range 0-2) for the surgical group versus 1(range 0-10) for the endoscopic group (p=0.02).Mean total length of stay-inclusive of readmissions and reinterventions- was similar between both groups (Surgical group= 9 days, Endoscopy =18.1 days, P=0.087)
Conclusion. Minimally invasive cystgastrostomy and necrosectomy is safe and feasible for the management of WOPN with similar success and complication rates compared to the endoscopic approach. It may be considered as the intervention of choice when combined with cholecystectomy for biliary etiology.
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