Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis

Am Surg. 2019 Aug 1;85(8):840-847.

Abstract

The role of surgical intervention for necrotizing pancreatitis has evolved; however, no widely accepted algorithm has been established to guide timing and optimal modality in the minimally invasive era. This study aimed to retrospectively validate an established institutional timing- and physiologic-based algorithm constructed from evidence-based guidelines in a high-volume hepatopancreatobiliary center. Patients with necrotizing pancreatitis requiring early (≤six weeks from symptom onset) or delayed (>six weeks) surgical intervention were reviewed over a four-year period (n = 100). Early intervention was provided through laparoscopic drain-guided retroperitoneal debridement (n = 15) after failed percutaneous drainage unless they required an emergent laparotomy (due to abdominal compartment syndrome, bowel necrosis/perforation, or hemorrhage) after which conservative, sequential open necrosectomy was performed (n = 47). Robot-assisted (n = 16) versus laparoscopic (n = 22) transgastric cystgastrostomy for the delayed management of walled-off pancreatic necrosis was compared, including patient factors, operative characteristics, and 90-day clinical outcomes. Major complications after early debridement were similarly high (open 25% and drain-guided 27%), yet 90-day mortality was low (open 8.5% and drain-guided 7.1%). Patient and operative characteristics and 90-day outcomes were statistically similar for robotic versus laparoscopic transgastric cystogastrostomy. Our evidence-based algorithm provides a stepwise approach for the management of necrotizing pancreatitis, emphasizing minimally invasive early and late interventions when feasible with low morbidity and mortality. Robot-assisted transgastric cystogastrostomy is an acceptable alternative to a laparoscopic approach for the delayed treatment of walled-off pancreatic necrosis.

Publication types

  • Validation Study

MeSH terms

  • Adult
  • Algorithms*
  • Cystotomy / methods
  • Cystotomy / statistics & numerical data
  • Debridement / adverse effects
  • Debridement / methods
  • Drainage / mortality
  • Drainage / statistics & numerical data
  • Evidence-Based Medicine
  • Female
  • Gastrostomy / methods
  • Gastrostomy / statistics & numerical data
  • Humans
  • Laparoscopy / adverse effects
  • Laparoscopy / statistics & numerical data
  • Male
  • Middle Aged
  • Pancreatitis, Acute Necrotizing / mortality
  • Pancreatitis, Acute Necrotizing / pathology
  • Pancreatitis, Acute Necrotizing / surgery*
  • Practice Guidelines as Topic
  • Retrospective Studies
  • Robotic Surgical Procedures / adverse effects
  • Robotic Surgical Procedures / statistics & numerical data
  • Time-to-Treatment*
  • Treatment Outcome