Infected necrotizing pancreatitis is now routinely treated with minimally invasive approaches after studies demonstrated increased morbidity for open necrosectomy. Current minimally invasive approaches commonly employ a “step-up” approach using percutaneous catheter or endoscopic ultrasound (EUS) guided stent placement and, as needed, subsequent formal necrosectomy via endoscopic or surgical (laparoscopic or retroperitoneal “video-assisted”) routes. In this study, 66 patients with suspected or confirmed infected necrosis were randomized in one center to step-up therapy via endoscopic therapy vs. minimally invasive surgery. While there was no significant difference in mortality (endoscopy 8.8% vs surgery 6.3%; P=.999), during 6 months of follow-up, endoscopic management yielded fewer major complications or death than did surgical management (11.8% endoscopy, 40.6% surgery, RR 0.29, 95% CI 0.11-0.80), fewer disease-related complications (5.9% vs 43.8%, p<0.001), fewer pancreatic- or entero-cutaneous fistulae (0% vs. 28.1%, p=0.001), higher physical health quality of life scores (P=.039), and lower total costs (P=.039).
Current algorithms seek to defer invasive treatment of pancreatic necrosis until it matures into walled-off necrosis (WON), which typically requires 4-6 weeks. Development of secondary infection often advances the timetable for intervention, thus commonly employing a percutaneous route. The endoscopic interventions fared significantly better than the surgical interventions, likely related to numerous characteristics, including avoidance of the surgically induced systemic inflammatory response syndrome (SIRS), more focal targeting of multiple complex tracts of infected necrosis, ease of employing multiple drainage routes, and long-term preservation of internal cyst-gastrostomy drainage in patients with disconnected ducts. Numerous aspects of the endoscopic algorithm are open to variation, based upon disease presentation and local standards of practice, but, clearly, this route provides more optimal outcomes in the majority of patients. Indeed, three patients deemed too sick to manage surgically had successful outcomes by crossover to endoscopic treatment. It is important to note that patients with early stage collections not amenable to endoscopic drainage were excluded from the study.
Bang JY, Arnoletti JP, Holt BA, et al. An endoscopic transluminal approach, compared to minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis. Gastroenterology 2018 Nov 16. (Epub ahead of print) (https://doi.org/10.1053/j.gastro.2018.11.031