Management of Pancreatic Necrosis: A Comparison of Conservative, Percutaneous, Endoscopic, and Surgical Modalities and Their Clinical Outcomes

Abstract

Introduction: Pancreatic necrosis is a morbid complication occurring in about 20% of patients with acute pancreatitis. Symptomatic sterile necrotic cavities and infected cavities are indications for drainage and debridement. Different modalities of treating pancreatic necrosis include conservative management, percutaneous drainage, endoscopic debridement and open surgical debridement. This study compares the clinical outcomes of all these modalities. Methods: We analyzed the period from December 2010 to October 2015 where 85 patients were treated for pancreatic necrosis at our hospital. We collected data with regards to their hospital course, investigational workup, management modalities utilized to treat them, complication rates, failure rates, ICU admission rate and mortality. Results: The mean age of patients was 54 ± 15 years. The major modality of therapy utilized was endoscopic necrosectomy (57.6%) (Figure 1) Overall rate of major and minor complications was 30.6% each. A logistic regression analysis did not find any difference in major complications between all 5 modalities. However, subgroup analysis revealed interesting results. (Table 1) Percutaneous drainage was associated with the highest re-intervention rate, ICU admission rate and certain major complications like intraabdominal bleeding, septic shock and/or multiorgan failure. Surgical necrosectomy was associated with a high ICU admission rate and the longest median length of ICU stay, however that may have been the case if patients needing surgery were very sick to begin with. Adjusted laboratory values pre- and postprocedure showed that percutaneous drainage had the highest impact in reducing the total white blood cell count whereas, surgical necrosectomy was associated with significant worsening of renal failure. Overall mortality rate at 30 days was 4%.Figure 1Figure 2Conclusion: Our study shows that each modality of treating pancreatic necrosectomy has its own advantages and disadvantages, with statistical analysis not revealing any significant difference. However, percutaneous drainage fared poorly compared to other interventions, possibly due to a higher systemic inflammatory response following puncture of the cystic cavity. Further research analyzing survival rates and hospitalization costs is needed to determine whether any particular procedure is superior to the others. For now, endoscopic necrosectomy seems to be the safer procedure with the least amount of morbidity or mortality.