Outcomes in Endoscopic and Operative Transgastric Pancreatic Debridement

Abstract

Objectives: Select patients with anatomically favorable walled off pancreatic necrosis may be treated by endoscopic (Endo-TGD) or operative (OR-TGD) transgastric debridement (TGD). We compared our experience with these 2 approaches. Summary Background Data: Select necrotizing pancreatitis (NP) patients are suitable for TGD which may be accomplished endoscopically or surgically. Limited experience exists contrasting these techniques exists. Methods: Patients undergoing Endo-TGD and OR-TGD at a single, highvolume pancreatic center between 2008 and 2019 were identified from a prospective database. Patient characteristics, procedural details, and outcomes of these 2 groups were compared. Results: Among 498 NP patients undergoing necrosis intervention, 160 (32%) had TGD: 59 Endo-TGD and 101 OR-TGD. The groups were statistically similar in age, comorbidity, pancreatitis etiology, necrosis anatomy, pancreatitis severity, and timing of TGD from pancreatitis insult. OR-TGD required 1.1 AE 0.5 and Endo-TGD 3.0 AE 2.0 debridements/patient. Fewer hospital readmissions and repeat necrosis interventions, and shorter total inpatient length of stay were observed in OR-TGD patients. New-onset organ failure [Endo-TGD (13%); OR-TGD (13%); P ¼ 1.0] was similar between groups. Hospital length of stay after TGD was significantly longer in patients undergoing Endo-TGD (13.8 AE 20.8 days) compared to OR-TGD (9.4 AE 6.1 days; P ¼ 0.047). Mortality was 7% in Endo-TGD and 1% in OR-TGD (P ¼ 0.04). Conclusions: Operative and endoscopic transgastric debridement achieve necrosis resolution with different temporal and procedural profiles. Clear multidisciplinary communication is essential to determine appropriate approach to individual necrotizing pancreatitis patients.

Contemporary Surgical Management of Pancreatic Necrosis

“…The anatomy of the patient's necrosis and their physiology determine the appropriate techniques for the step-up approach. The pros and cons of different techniques are described in the Table, 11,[13][14][15][16][17][18][19][20][21][22] and a general treatment algorithm for their use is depicted in Figure 2. 16 There is no overarching evidence demonstrating that one technique is preferred over another in the step-up armamentarium, but instead, the sequence of interventions is guided by the particular circumstance of each individual.…”

“…Compared with ETN, STN provides the opportunity to perform extensive debridement at the index operation and maintains the advantage of internal drainage of the necrosis cavity, while often avoiding the multiple procedures typically required with less invasive techniques. 18,22 For patients with disconnected pancreatic tail segments, the surgical anastomosis to the necrosis cavity may provide more durable internal drainage than stent- A, An intercostal, transperitoneal drainage route that accesses the end of the walled-off necrosis and would allow debridement via sinus tract endoscopy. Accessing the end of the cavity as opposed to the middle allows access to the entire cavity.…”

Potential of Minimally Invasive Drainage Interventions for Acute Pancreatitis

“…В заключение следует отметить, что чрескожное и трансмуральное эндоскопическое дренирование относятся к наиболее распространенным и зффективным методам первой линии миниинвазивного лечения пациентов с отграниченным панкреонекрозом. Эндоскопическое трансмуральное дренирование может быть более предпочтительной процедурой, поскольку позволяет избежать риска образования наружных панкреатических свищей [3,8,60].…”

Clinical outcomes following endoscopic or video‐assisted retroperitoneal management of acute pancreatitis with large (>15 cm) walled‐off pancreatic necrosis: Retrospective, single tertiary center cohort study

“…5,6,[9][10][11][12] As previous clinical studies mainly focused on WON ranging from 8 to 15 cm in diameter, data about the efficacy of endoscopic and video-assisted retroperitoneal treatment of WON larger than 15 cm are scarce. 8,10,[13][14][15][16][17][18][19][20] A recent study clearly demonstrated that the localization and size of extra pancreatic necrosis are associated with clinical outcomes, including mortality, LOS, and intensive care unit (ICU) stay in patients with acute necrotizing pancreatitis. 21 Thus, there is an unmet need for data to assess the efficacy and safety of a minimally invasive treatment approach for large WON, especially if large WON can be managed without open necrosectomy.…”

“…As previous clinical studies mainly focused on WON ranging from 8 to 15 cm in diameter, data about the efficacy of endoscopic and video‐assisted retroperitoneal treatment of WON larger than 15 cm are scarce 8,10,13–20 . A recent study clearly demonstrated that the localization and size of extra pancreatic necrosis are associated with clinical outcomes, including mortality, LOS, and intensive care unit (ICU) stay in patients with acute necrotizing pancreatitis 21 .…”