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Surgical Transgastric Necrosectomy for Symptomatic Pancreatic Necrosis in Acute Necrotizing Pancreatitis
Jessica Cioffi*, Jose Trevino, Steven J. Hughes, Kevin E. Behrns
Surgery, University of Florida, Gainesville, FL
Introduction: Historically, the management of symptomatic pancreatic necrosis has required necrosectomy with external drainage. Recently, endoscopic approaches have prevailed however these require significant maturation of the necrosis cavity and multiple debridements prolonging the duration of symptoms. At our institution, we have selectively applied early transgastric necrosectomy without external drainage for patients with symptomatic pancreatic necrosis.
Methods: A retrospective analysis of a prospectively collected database was performed to identify all patients over a 3 year period (1/2012-1/2015) that underwent transgastric surgical necrosectomy for symptomatic pancreatic necrosis in the setting of acute necrotizing pancreatitis (ANP) at a single academic institution. This was performed via creation of a cystgastrostomy with transgastric pancreatic debridement.
Results: Eighteen patients were identified with ANP that selectively underwent transgastric necrosectomy. Fifty-six percent of the patients were male with a median age of 50 years, BMI of 27, and ASA score of 3. Ten patients (56%) presented with a biliary etiology and 5 (28%) due to alcohol. Five patients (28%) presented with severe ANP, 5 (28%) with moderately-severe ANP, and 8 (44%) with mild ANP. No patients had prior intervention or drain placement. Cross-sectional imaging demonstrated mature necrotic pancreatic fluid collections in all patients while 14 (78%) had a disconnected pancreatic duct and 6 (33%) had retrocolic extension of the necrosis cavity. Median time to surgical intervention was only 41 days with 33% of interventions performed laparoscopically and 67% via a small upper midline incision. Fifty percent of patients had a concomitant cholecystectomy and 72% had a feeding tube placed. Median operative time was 114 minutes with an EBL of 100ml. Morbidity was 50% for all patients (Clavien-Dindo classification: Grade 1 44%, Grade 2 11%, Grade 3 22%, Grade 4 11%, Grade 5 11%) with a 6% mortality rate. Median postoperative length of stay was 9 days. No patients developed new onset organ failure or pancreatic fistula following surgery. Two patients required reoperation within 30 days for persistent fluid collections and 11% required angiographic embolization for a bleeding pseudoaneurysm. Fifty percent of patients developed pancreatic exocrine insufficiency with 33% developing endocrine insufficiency. Two patients required subsequent surgical intervention for development of a pancreatic duct stricture >20 months after necrosectomy.
Conclusion: Early surgical transgastric necrosectomy for symptomatic pancreatic necrosis appears to be safe and feasible without the need for multiple interventions or the development of chronic pancreatic fistula. Further study is needed to determine if this early approach positively impacts the duration of disability or quality of life.
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