NEW YORK (Reuters Health) – In the highest-risk patients with necrotizing pancreatitis, endoscopic and minimally invasive surgical necrosectomy are associated with lower mortality risk than open necrosectomy, according to data pooled from 15 cohorts in eight countries.
“This is the largest international cohort of patients with necrotizing pancreatitis who underwent a necrosectomy,” corresponding author Dr. Sandra van Brunschot of the Academic Medical Center, Amsterdam, told Reuters Health by email. “Moreover, this study was novel in performing a head-to-head comparison of patients undergoing different methods of necrosectomy.”
The researchers combined original study data from 1,980 patients who had undergone pancreatic necrosectomy at 51 hospitals on four continents: 1,167 with open necrosectomy, 467 with minimally invasive surgical necrosectomy, and 346 with endoscopic necrosectomy. In all, 325 patients (16%) died during the index admission.
The researchers conducted a propensity score-matched analysis in which patients were stratified into four groups according to their predicted mortality risk at baseline (very high, high, intermediate, and low).
Among patients in the very highest-risk group (baseline risk of at least 35%), minimally invasive surgical necrosectomy was associated with a significantly lower risk of death (risk ratio, 0.70), as was endoscopic necrosectomy (RR, 0.43), compared with open necrosectomy.
Patients in the next-highest risk group (baseline risk 15% to <35%) also had a significantly lower risk for death if they underwent endoscopic, rather than open, necrosectomy (RR, 0.27). The advantage of minimally invasive surgery did not reach statistical significance in this subgroup.
Intermediate-risk and low-risk patients did not show a statistically significant advantage with the less-invasive procedures.
Open necrosectomy was associated with increased risk for pancreatic fistula.
“Our results suggest that patients with necrotizing pancreatitis who are severely ill should undergo minimally invasive surgical or endoscopic necrosectomy instead of open necrosectomy,” Dr. van Brunschot said, assuming that expertise in these techniques is available. Though there are still centers worldwide that perform a primary open necrosectomy in such patients, she said, she expects that the number of open necrosectomies will continue to decline.
Open necrosectomy to treat necrotizing pancreatitis is now rare, agreed Dr. Gareth Morris-Stiff, a pancreatic surgeon at the Cleveland Clinic. “Most centers with dedicated pancreatic specialists have already changed their surgical approach and prefer to use minimally invasive surgery to treat necrotizing pancreatitis,” he continued, except “in difficult scenarios such as necrosis at the base of the mesentery or in the paracolic gutters.”
“The paper . . . includes experts from around the world and a good number of patients,” Dr. Morris-Stiff told Reuters Health by email. “The authors wrote a strong paper, and their analysis contributes evidence to existing research on best surgical practices to treat necrotizing pancreatitis.”
SOURCE: http://bit.ly/2vrb4eU
Gut 2017.
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