Minimally Invasive Pancreatic Necrosectomy: A step-up approach towards ultra-low mortality in 103 consecutive procedures

Abstract

Introduction: Infected pancreatic necrosis carries up to 70% risk of mortality. Open necrosectomy, previously regarded as standard treatment, carries very high risk of morbidity and mortality. Step-up management with percutaneous drainage followed by minimally invasive pancreatic necrosectomy (MIPN) has shown improved outcomes. We report the outcomes of the protocol developed at Cambridge of ‘early’ percutaneous drainage followed by ‘delayed’ MIPN. Method: Cambridge University Hospital is a tertiary referral centre for pancreatic surgery including complicated pancreatitis. Retrospective analysis of all MIPNs between December 2009 and October 2018. Demographics, morbidity and mortality outcomes are reported. Result: During the 9-year period, 103 MIPNs were performed in 86 patients, with 12 (13.9%) needing multiple procedures. The mean age was 58 ±15 years, with 74.4% (n=64) being male gender and 50.0% (n=43) with BMI more than 30 Kg/m2.Thirty (34.9%) patients had required preoperative ITU admission for multi-organ support related to infected necrosis. The mean time for insertion of percutaneous drain was 28 days (range 1-99). The mean time of the MIPN from acute episode was 45 days (range 4-307). Thirteen patients (15.1%) required admission to ITU after MIPN with a mean stay of 22 days (range 1-104). Composite endpoint for complications including bleeding needing intervention (n=5), multi-organ failure (19) and fistula (5) were 29 (33.7%), which was considered as the morbidity rate. 30-day and 90-day mortality following MIPN was 2.3% (n=2) and 5.8% (n=5), all deaths were due to sepsis and multi-organ failure. Conclusion: This is the lowest reported mortality rate for patients with infected pancreatic necrosis. Minimally invasive management with early percutaneous drain insertion followed by delayed MIPN is associated with ultra-low mortality. Management of complicated necrotizing pancreatitis almost invariably requires tertiary referral expertise as multimodal approaches, complex medical and ITU involvement, multiple procedures, prolonged admissions and long-term follow-up.