Laparoscopic transgastric necrosectomy reduces re-intervention and morbidity compared to open necrosectomy

Abstract

Background: Operative intervention for persistent or infected pancreatic necrosis is highly morbid. Recently, laparoscopic trans-gastric necrosectomy (LTGN) has emerged as an alternative to open necrosectomy (ON) in select patients. We sought to compare the two techniques in well-matched instances. Methods: Using an institutional database of 403 cases of pancreatitis requiring procedural intervention, we abstracted 30 cases of LTGN and matched them to 22 cases of open debridement. Cases were matched on the basis of age, gender, indication, confirmed pre-op infection, presence of SIRS at operation, multiple organ dysfunction score, and overall percent necrosis. We compared the groups for operative characteristics, number of procedures, and pancreatic fistula following debridement. Results: Fifty-two cases were included (LTGN = 30, ON = 22). There were no differences in the matched categories selected. Open drainage was associated with greater operative blood loss (median 500 cc [IQR: 212–1000] vs 25 cc [20–81] p < 0.001), transfusions (83% vs 17% p < 0.001), length of stay (15.5 d [8.5–28.5] vs 4.0 d [3.0–8.4] p < 0.001). No difference in hospital, 30 d or 90 d mortality were seen. Major complications were seen in 82% of ON vs 29% of LTGN (p = 0.001). ON was associated with increased number of total postoperative drainage interventions (1.5 [1.0–2.3] vs 1.0 [1.0–1.0] p = 0.003), increased rates of pancreatic fistula (36.4% vs 0%, p = 0.001), and total operations [1.8 [1.0–2.0] vs 1.0 [1.0–1.0] p = 0.001). There were no differences in rates of endocrine insufficiency, or development of hernia. Conclusion: Pancreatic necrosis remains a challenging clinical entity with a range of interventions available. Laparoscopic transgastric necrosectomy is a novel approach allowing for both durable drainage and definitive debridement that limits the morbidity of an open approach.