THE POTENTIAL CLINICAL BENEFITS OF DIRECT SURGICAL TRANSGASTRIC PANCREATIC NECROSECTOMY FOR PATIENTS WITH INFECTED NECROTIZING PANCREATITIS
Hester C. Timmerhuis*1, Rejoice F. Ngongoni1, Amy Y. Li1, Jonathan DeLong1, Sean P. McGuire2, Kyle A. Lewellen2, Monica M. Dua1, Komal Chughtai1, Nicholas J. Zyromski2, Brendan Visser1
1Surgery, Stanford University School of Medicine, Stanford, CA; 2Indiana University School of Medicine, Indianapolis, IN
Background
The step-up approaches – percutaneous or endoscopic catheter drainage followed, if necessary, by minimally invasive surgical or endoscopic necrosectomy – are leading approaches for infected necrotizing pancreatitis after trials showed reduced morbidity compared to traditional open surgical necrosectomy. However, both the surgical and endoscopic step-up approaches are associated with the need for repeat interventions and prolonged hospitalization. The surgical transgastric approach to pancreatic necrosectomy (direct STGN) has been introduced for retrogastric collections to overcome these shortcomings. In this study, we aimed to describe outcomes for patients who have undergone direct STGN for infected necrosis.
Methods
This observational cohort study included patients who underwent direct STGN for infected pancreatic necrosis between 2011 and 2022 at two centers. Patients with sterile necrosis, a prior pancreatic intervention (i.e., interventional radiology drain, endoscopic transgastric drain) or a laparotomy after diagnosis of pancreatitis prior to STGN were excluded from analysis. Primary outcomes included mortality, length of hospital and intensive care unit (ICU) stay, new-onset organ failure, repeat interventions, readmissions and time to disease resolution (defined as the date of removal of the last percutaneous drain or date of discharge of initial admission or readmission).
Results
Forty-five patients underwent direct STGN for infected necrosis (21 open, 24 laparoscopic). The median age was 57 years (IQR 46–62) and 14 patients (31.1%) were female. On pre-operative imaging, 29 (64.4%) patients had more than 30% pancreatic necrosis. The median time to intervention from diagnosis of acute pancreatitis was 48 days (IQR 32–70). Pancreatitis-related mortality rate was 6.7% (n = 3). Following direct STGN, the median length of hospital stay was 8 days (IQR 6–17). ICU admission was required in 23 patients (51.1%) for a median of 1 day (IQR 0–3). New-onset organ failure occurred in 8 patients (17.8%). In 10 patients (22.2%), a surgical drain was left intraoperatively. Two patients (4.4%) required re-intervention (1 interventional radiology drain, duration 101d; 1 endoscopic transgastric drain). A pancreatic fistula was seen in one patient (2.2%). Eleven patients (24.4%) were readmitted. The median time to disease resolution was 6 days (IQR 6–22).
Conclusion
When anatomically possible, direct STGN offers an opportunity to treat patients with infected necrosis in a single procedure resulting in a short time to disease resolution. Due the low need for repeat interventions and few pancreatic fistulas, the direct STGN challenges the step-up approach for infected necrosis. Additional research is required to compare the different approaches.
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