P-EUS03 Risk prediction in patients undergoing Endoscopic Necrosectomy for infected pancreatic necrosis

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Abstract Background Laparotomy for the treatment of patients with infected pancreatic necrosis is associated with high rates of morbidity (∼95%) and mortality (∼50%); this has driven the development of minimally invasive alternatives for the treatment of such cases. Endoscopic Transgastric Necrosectomy (ETN) is an accepted method for debriding infected necrosis in these challenging cases. The National Emergency Laparotomy Audit (NELA) and P-POSSUM scoring systems are well-validated risk stratification tools used nationally for patients undergoing emergency laparotomy. This work aims to determine whether patients undergoing ETN for infected pancreatic necrosis can be risk stratified accurately using both the NELA and P-POSSUM scoring systems. Methods A prospective database of all patients in a single UK centre undergoing ETN from 2011 to 2021 for infected pancreatic necrosis has been maintained. All patients initially underwent an EUS guided stent placement to create a cystgastrostomy before subsequent transgastric necrosectomy. Patient demographics, timing of procedures and short-term post procedural outcomes were recorded. The NELA and P-POSSUM score was calculated at the time of the endoscopic cystgastrostomy. Demographic data were descriptively summarized and ROC analysis was performed to assess the diagnostic accuracy of both the P-POSSUM and NELA score. Data are presented as median (range) Results Sixty-nine patients underwent ETN between 2011 and 2021 with a median age of 54 years-(15-86). Twenty-nine patients-(42%) required ITU admission during their admission. The actual mortality was 10.1%-(7), which was slightly higher than the median of the NELA predicted mortality-(6.7%) but half the median of the P-POSSUM predicted mortality-(21.1%). Median overall predicted mortality for ETN using P-POSSUM was 21.1%-(2.6-85.7%) and with NELA was 6.7%-(0.4-34.3%). The median P-POSSUM score of the patients who died was 33.2%-(6.9-52.4%) compared to the median NELA score which was 17.2%-(0.8-34.3%). The area under the receiver operating characteristics curve-(AUROC) was similar for both the NELA-(0.82, SE = 0.13) and P-POSSUM-(0.75,-SE=0.1). Conclusions Endoscopic Transgastric Necrosectomy is a safe alternative to emergency laparotomy for the debridement of infected pancreatic necrosis. Both the NELA and P-POSSUM scoring systems can effectively stratify those patients at highest risk, however where P-POSSUM scoring may overestimate mortality NELA scoring may underestimate the severity of illness and mortality associated with the disease.