Improved Mortality in Necrotizing Pancreatitis With A Multidisciplinary Minimally Invasive Step Up Approach: Comparison To A Modern Open Necrosectomy Cohort
*Casey M Luckhurst, *Ahmed E Elsharkawy, *Ahmed I Eid, *Majed El Hechi, *Lydia M Maurer, Haytham M Kaafarani, *Ashraf Thabet, *David G Forcione, Carlos Fernandez-Del Castillo, Keith D Lillemoe, *Peter J Fagenholz
Massachusetts General Hospital, Boston, MA
Objective: Evaluate the mortality of a minimally invasive step-up (MIS) approach to necrotizing pancreatitis (NP) compared to open surgical necrosectomy (OSN).
Design: Observational cohort study with retrospective comparison. 1 year follow up.
Setting: Single tertiary referral center. 2006-2019.
Patients: Of 184 patients who underwent intervention for NP, n=88 underwent OSN and n=94 had an MIS approach. We excluded patients with prior OSN/MIS at other institutions before transfer (n=8). Groups were compared using age, gender, ASA, APACHE II, etiology, and presence of infection. Patients were followed for 1 year after first intervention, with 100% follow up.
Interventions: Until 2013 we exclusively used an open transperitoneal approach to necrosectomy. Beginning in 2013 we transitioned to an MIS approach. MIS interventions included percutaneous drainage (PD) alone, endoscopic transgastric necrosectomy (ETN), video-assisted retroperitoneal debridement (VARD), sinus tract endoscopic necrosectomy (STE), or a combination of techniques, with selective use of OSN.
Main Outcome Measure: Primary outcome was mortality at one year following first NP intervention.
Results: There was no difference in baseline characteristics, except for etiology (p=0.015). MIS Group: 11% (n=10) treated with PD, 31% (n=29) with ETN, 13% (n=12) with VARD, 12% (n=11) with STE, and 27% (n=26) with a combination of techniques. Overall mortality was 2% (n=2) with MIS compared to 13% (n=11) in the OSN group (p=0.008).
Conclusions: Adoption of a multidisciplinary MIS approach to pancreatic necrosectomy has resulted in a 6-fold decrease in mortality. A multidisciplinary approach with a variety of techniques is necessary for optimal care of these complex patients. 
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