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Bret T. Petersen, MD, FASGE

Associate Editor
Pancreatobiliary

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Biography

Bret T. Petersen, MD, FASGE is Professor of Medicine in the Division of Gastroenterology and Hepatology at the Mayo Clinic in Rochester, Minnesota. His practice is focused in the Mayo Pancreas Clinic and the Advanced Endoscopy Group. His professional interests include pancreatic and biliary diseases, performance and outcomes of ERCP, and delivery of endoscopic services. At Mayo, Dr. Petersen is a past Director of Endoscopy and has served on multiple clinic and foundation committees. He has directed numerous American Society for Gastrointestinal Endoscopy (ASGE) and Mayo courses, particularly related to the performance of ERCP. He has received the Mayo Award for Excellence, GI Fellows Award for Outstanding Teacher, and Department of Medicine Laureate Award (GI), as well as the Master Endoscopist Award of the ASGE. Dr. Petersen is the incoming Secretary for (ASGE) and a past Chair of the Technology and Quality Assurance in Endoscopy committees.

Disclosures

Consultant 

Boston Scientific 

Advisory Board 

Ethicon/J & J

 

Summaries

Infected Pancreatic Necrosis Best Treated By Endoscopic Drainage

Bret T. Petersen, MD, FASGE reviewing Bang JY, et al. Gastroenterology 2018 Nov 16.

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).

Comment:
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.
Note to readers:
At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Bret T. Petersen, MD, FASGE
Bio and Disclosures

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Citation(s):
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)