Disconnected left pancreatic remnant following necrosectomy for severe pancreatitis can be managed without pancreatectomy: an international, multicenter analysis

Abstract

Background: Disconnected left pancreatic remnant (DLPR)—a viable tail disconnected by necrosis--following severe acute necrotizing pancreatitis has been an indication for completion distal pancreatectomy, a highly morbid procedure. Surgical transgastric necrosectomy (TGN) is novel alternative to other debridement strategies because it explicitly creates an internal fistula (cystgastrostomy). We sought to characterize the natural history of DLPR after TGN. Methods: Using data from a multicenter, international database, we evaluated 121 patients (31% female, median age 51yrs) who underwent TGN for walled-off pancreatic necrosis between (2002-18). All clinicopathologic data were abstracted from medical records. The location of necrosis was identified based on preoperative imaging and those with subset of patients were analyzed. Results: Of the 121 patients, 52 had DLPR prior to necrosectomy. The etiologies in this subset were etiologies were biliary (40%), alcohol-related (40%), iatrogenic (8%), hypertriglyceridemia (4%), and idiopathic (8%). Median ASA was 3. Indication for TGN was infected necrosis in 27% and persistent illness (73%). While most (94%) had lesser-sac necrosis, 32% involved the root-of-mesentery and 17% the paracolic-gutter. Fourteen cases (27%) were performed laparoscopically, one required conversion-to-open. Median follow-up was 11 months (1-60 mo). Morbidity (any complication) was 30% with one mortality; 12 patients required readmission. There was one reoperation and one postop pancreatic fistulae per group. There were no significant differences between transgastric necrosectomies with or without DLPRs. Conclusions: Necrotizing pancreatitis with DLPR may be successfully managed with a single-stage transgastric necrosectomy, avoiding persistent fistulas, drains, or need for reoperation to address the DLPR.