Invasive Step-up Approach Research Articles

Step-Up versus Open Approach in the Treatment of Acute Necrotizing Pancreatitis: A Case-Matched Analysis of Clinical Outcomes and Long-Term Pancreatic Sufficiency.

Background/Objectives: Acute necrotizing pancreatitis (ANP) with secondary infection of necrotic tissue is associated with a high rate of complications and mortality. The optimal approach is still debatable, but the minimally invasive modality has gained great attention in the last decade as it follows the principle of applying minimal surgical trauma to achieve a satisfying therapeutic objective. We compared clinical outcomes between the step-up approach (SUA) and open necrosectomy (ON) in the treatment of acute necrotizing pancreatitis. Methods: A prospective cohort study over the period of 2011-2021 in a university teaching hospital was performed. Results of 99 consecutive patients with ANP who required surgical/radiological intervention were collected. A case match analysis (2:1) was performed, and the final groups comprised 40 patients in the OA group and 20 patients in the SUA group. Demographic, clinicopathologic, and treatment data were reviewed. Results: Baseline characteristics and disease severity were comparable between the two groups. The patients from the SUA group had a significantly lower morbidity rate and rate of pancreatic insufficiency. Death occurred in 4 of 20 patients (20%) in the SUA group and in 11 of 40 patients (27.5%) in the ON group (risk ratio with the step-up approach, 0.72; 95% confidence interval, 0.26 to 1.99; p = 0.53). Conclusions: A minimally invasive step-up approach provides comparable outcomes to open necrosectomy in the treatment of ANP with infected pancreatic necrosis. While mortality and hospital stay were comparable between the groups, morbidity and pancreatic insufficiency were significantly lower in the SUA group. Further studies on a larger number of patients are required to define the place of SUA in the modern treatment of ANP.

Endoscopic Ultrasound-Guided Drainage of Pancreatic Fluid Collections: Not All Queries Are Already Solved.

Pancreatic fluid collections (PFCs) are well-known complications of acute pancreatitis. The overinfection of these collections leads to a worsening of the prognosis with an increase in the morbidity and mortality rate. The primary strategy for managing infected pancreatic necrosis (IPN) or symptomatic PFCs is a minimally invasive step-up approach, with endosonography-guided (EUS-guided) transmural drainage and debridement as the preferred and less invasive method. Different stents are available to drain PFCs: self-expandable metal stents (SEMSs), double pigtail stents (DPPSs), or lumen-apposing metal stents (LAMSs). In particular, LAMSs are useful when direct endoscopic necrosectomy is needed, as they allow easy access to the necrotic cavity; however, the rate of adverse events is not negligible, and to date, the superiority over DPPSs is still debated. Moreover, the timing for necrosectomy, the drainage technique, and the concurrent medical management are still debated. In this review, we focus attention on indications, timing, techniques, complications, and particularly on aspects that remain under debate concerning the EUS-guided drainage of PFCs.

Is Contemporary Open Pancreatic Necrosectomy Still Useful In The Minimally Invasive Era?

BackgroundPrevious studies have shown that open pancreatic necrosectomy for infected pancreatic necrosis was associated with high morbidity and mortality. However, these results were mostly concluded from historical cohorts with traditional early necrosectomy in the absence of a minimally invasive step-up approach. ObjectiveTo explore the value of contemporary open pancreatic necrosectomy for infected pancreatic necrosis in the minimally invasive era. MethodsA post hoc analysis was performed in a prospective maintained database of 320 patients with infected pancreatic necrosis from January 2011 to December 2022 at a large Chinese tertiary hospital. ResultsA total of 320 patients with infected pancreatic necrosis received either a minimally invasive step-up approach (245, 76.6%) or open pancreatic necrosectomy (75, 23.4%), which included upfront open pancreatic necrosectomy (32, 10.0%) and salvage open pancreatic necrosectomy (43, 13.4%). Upfront open pancreatic necrosectomy was associated with similar morbidity and mortality rates but fewer surgical interventions compared with a minimally invasive step-up approach. However, salvage open pancreatic necrosectomy was associated with significantly higher mortality (48.8% vs 18.8%, P = .007), gastrointestinal fistula (44.2% vs 18.8%, P = .021), hemorrhage (48.8% vs 15.6%, P = .003), and intensive care unit stay (25 vs 7 days, P = .040) compared with upfront open pancreatic necrosectomy. Multivariate analysis suggested that multiple organ failure (hazard ratio = 5.1; 95% confidence interval, 1.4–18.2, P = .013) and synchronous critical acute pancreatitis (hazard ratio = 3.0; 95% confidence interval, 1.1–8.6, P = .040) were 2 independent risk factors of death for patients who received open pancreatic necrosectomy. ConclusionPatients undergoing upfront open pancreatic necrosectomy received fewer surgical interventions with comparable efficacy compared to the minimally invasive step-up approach. Salvage open pancreatic necrosectomy was potentially lifesaving, though it carried high morbidity and mortality. Multiple organ failure and synchronous critical acute pancreatitis were 2 independent risk factors of death for patients who received open pancreatic necrosectomy.

Nomogram development and validation for predicting minimally invasive step-up approach failure in infected necrotizing pancreatitis patents: a retrospective cohort study.

Previous studies have shown that minimally invasive treatment for infected necrotizing pancreatitis (INP) may be safer and more effective than open necrosectomy (ON), but ON is still irreplaceable in a portion of INP patients. Furthermore, there is a lack of tools to identify INP patients at risk of minimally invasive step-up approach failure (eventually received ON or died), which may enable appropriate treatment for them. Our study aims to identify risk factors that can predict minimally invasive step-up approach failure in INP patients and to develop a nomogram for early prediction. Multivariate logistic regression was performed to evaluate the association between minimally invasive step-up approach failure and factors regarding demographics, disease severity, laboratory index and the location of extrapancreatic necrotic collections. A novel nomogram was developed, and its performance was validated both internally and externally by its discrimination, calibration, and clinical usefulness. There were 267, 89, and 107 patients in the training, internal and external validation cohorts, respectively. Multivariate logistic regression demonstrated that the CT severity index (CTSI) greater than 8 points, Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 16 points or more, early spontaneous bleeding, fungi infection, granulocyte and platelet decrease within 30 days of acute pancreatitis onset, and extrapancreatic necrosis collection located in small bowel mesentery were independent risk factors for minimally invasive step-up approach failure. The area under the curve and coefficient of determination (R2) of the nomogram constructed from the above these factors were 0.920 and 0.644, respectively. The Hosmer-Lemeshow test showed that the model had a good fitness (P=0.206). In addition, the nomogram performed well in both the internal and external validation cohorts. The nomogram had a good performance in predicting minimally invasive step-up approach failure, which may help clinicians early distinguish INP patients at risk of minimally invasive step-up approach failure.

Comparative analysis of robotic transgastric cystogastrostomy in a community teaching hospital

Background: In 2010 the PANTER trial demonstrated that a minimally invasive step-up approach was safe and effective for necrotizing pancreatitis. Furthermore, a retrospective validation study for the treatment of necrotizing pancreatitis by Pickens, et al at Atrium Health in North Carolina, showed comparative outcomes for a laparoscopic and robotic approach. A hepatopancreaticobiliary (HPB) program was started in 2017 at a level 1 trauma center community teaching hospital (COMH). Currently, a single surgeon performs 60-70 HPB cases per year with 50% being robotic. We aim to compare the COMH robotic transgastric necrosectomy with cystogastrostomy results to those of a high volume HPB center.

Severe Pancreatitis Multidisciplinary Working Group: Exploratory Analysis to Optimize Care and Cost.

The minimally invasive step-up approach to pancreatitis improves outcomes. Multidisciplinary working groups may best facilitate this approach. However, support for these working groups requires funding. We hypothesize that patients requiring surgical debridement generate sufficient revenue to sustain these working groups. Furthermore, patients selected for surgical debridement by the working group will have a higher rate of percutaneous and endoscopic intervention in adherence to the step-up approach. We conducted an observational cohort study of all patients with severe acute and/or necrotizing pancreatitis whose care was overseen by our multidisciplinary working group (October 2015 through January 2019). Patient demographics, hospital treatments, and outcomes data were compared between those who underwent surgical debridement and those who did not. Hospital billing data were also collected from those who are undergoing surgical debridement and compared to institutional benchmarks for financial sustainability. A total of 108 patients received care overseen by the working group, 10 of which progressed to surgical debridement. The mean contribution margin percentages for each patient in the surgical debridement group were higher than the threshold value for financial sustainability, 39% (60.34%±16.66%; P=0.004). Patients in the surgical debridement group were more likely to undergo intervention by interventional radiologist (odds ratio, 1.58; P=0.005). The mortality was higher in the nonsurgical debridement group (odds ratio, 15; P=0.008). Our multidisciplinary working group delivered step-up care to patients with pancreatitis. Patients requiring surgical debridement generated a significantly positive contribution margin that could be used to help support the costs associated with providing multidisciplinary care.

Treatment and Prevention of Intraabdominal Bleeding in Necrotizing Pancreatitis Patients Treated With a Step-Up Approach.

A minimally invasive step-up (MIS) approach for management of necrotizing pancreatitis (NP) has been associated with reduced morbidity and mortality compared with open surgical techniques. We sought to evaluate bleeding complications in NP patients treated with a MIS approach and to describe the management and outcomes of these events. An observational, cohort study was performed using a prospectively maintained NP database at a tertiary referral center from 2013 to 2019. Of 119 NP patients, 13% suffering bleeding events, and 18% underwent an intervention. There was a 6-fold higher mortality rate in patients with bleeding events (n = 3; 18.8%) compared with those without (n = 3; 2.9%) ( P = 0.031). The most common intervention for hemorrhage control was endovascular coil embolization (75%), which was successful 88% of the time. Seven patients underwent prophylactic vascular intervention, which was 100% successful in preventing bleeding events from the embolized vessel. Bleeding events in NP patients treated with a MIS approach are associated with a 6-fold increase in mortality. Endovascular intervention is an effective strategy for the management of bleeding events. Prophylactic embolization may be an effective technique for reducing bleeding complications.

Contemporary Intervention in Necrotizing Pancreatitis: Improved Understanding Changing Practice

BackgroundTreatment of necrotizing pancreatitis (NP) has shifted in favor of a minimally invasive step-up approach rather than early open pancreatic debridement. We hypothesized that this paradigm shift would be reflected in the intervention, morbidity, and mortality profile of NP patients. Study DesignSingle-institution retrospective review of 767 NP patients treated between 2005 and 2019. Two eras of NP intervention were identified relative to the introduction of a minimally invasive approach to NP. Patients treated between 2005 and 2010 were classified as the “early” group and compared with patients treated between 2011 and 2019, classified as the “late” group. ResultsIn total, 299 NP patients comprised the early group and 468 patients comprised the late group. No differences were seen in patient demographics, comorbidity profile, or NP etiology between groups. Necrosis volume, necrosis location, CT severity index (CTSI), and rates of infected necrosis were similar between groups. No difference was seen in mortality. Mechanical intervention for NP was more common in the early than the late group (86% vs. 73%, p < 0.001). Time to first intervention was similar between groups (79 ± 7d vs. 75 ± 6d). The early group had higher rates of open pancreatic debridement (72% vs. 55%, p < 0.001). Endoscopic intervention was less common in the early than the late group (7% vs. 16%, p < 0.001). NP disease duration was longer in the early than the late group (223 ± 12d vs. 179 ± 7d, p = 0.001). ConclusionContemporary management of necrotizing pancreatitis is marked by less frequent operative debridement and shorter disease duration.

Operative Pancreas Debridement in 2021: Who and When?

Introduction: Treatment of necrotizing pancreatitis (NP) has shifted in favor of a minimally invasive step-up approach rather than primary operative pancreatic debridement (OPD). We evaluated the contemporary role of OPD in NP treatment. Methods: Single institution retrospective review of 468 NP patients treated between 2011-2019. Operative pancreatic debridement included video-assisted retroperitoneal debridement (VARD), open and minimally invasive transgastric debridement, and open debridement with external drainage. NP patients whose treatment included OPD were compared with patients treated definitively without OPD. Results: Since 2011, 256/468 (55%) of patients were treated with OPD. Gender and comorbidity profile were similar between groups. Necrotizing pancreatitis etiology was more likely biliary (52% vs 32%) and less likely secondary to alcohol (19% vs 35%) in patients treated with OPD (p<0.001). Computed tomography severity index (CTSI) of pancreatic necrosis was similar between groups; however, infected necrosis was more common in patients who underwent OPD (68% versus 33%, p <0.001). Patients treated with OPD were more likely to have disconnected pancreatic duct syndrome (DPDS) (53% vs 29%, p <0.001). Among patients who underwent OPD during their treatment, 73% underwent OPD as their initial intervention at 73 ± 6 days after disease onset while 27% underwent OPD as salvage therapy at 95 ± 16 days after disease onset, p=0.1. Conclusions: Operative pancreatic debridement remains an important treatment modality in patients with pancreatic necrosis. OPD is employed as either primary or salvage therapy most frequently in patients with NP of biliary etiology, infected necrosis, and patients with disconnected pancreatic duct.

Step-up mini invasive surgical treatment of patients with different morphological forms of acute necrotizing pancreatitis

Introduction: Despite significant progress in the treatment strategy of acute necrotizing pancreatitis (ANP), mortality in cases of its severe form remains high. There is no single point of view concerning the indications for the use of mini invasive interventions depending on the nature, extension and localization of the pathological foci of ANP. Material: We performed a prospective observational cohort study of efficacy of elaborated algorithmic mini invasive step-up approach of surgical treatment of 317 patients with different morphological forms of ANP. The following parameters were collected for each episode: length of hospital stay, mortality, occurrence of organ failure and local complications. Results: Transcutaneous punction/drainages were applied as the first step in 37 patients with acute necrotic collections (ANC). In the presence of walled-off pancreatic necrosis (WOPN) EUS procedures were preferred in case their close localization to the stomach or duodenum in 65 observations. Initial surgical treatment wasn't effective in 18.8% and video-assisted retroperitoneal debridement (VARD) in patients with ANC or necrosectomies under EUS control in cases of WOPN were applied. Necessary for laparotomic necrosectomies occurred in 14.5% of patients and was the final step of proposed algorithmic approach. During postoperative period complications occurred in 28.3% of patients. They included 7 new episodes of organ failure, 4 cases of arosive hemorrhage, and 5 observations of pancreatic and duodenal fistulas. Overall mortality rate was 3.3%, after interventional treatment - 6.5%. Conclusion: Surgical treatment in patients with ANP based on elaborated algorithmic step-up approach is followed by acceptable complication and mortality level.

Risk of gallstone-related complications in necrotizing pancreatitis patients treated with a step-up approach: The experience of two tertiary care centers

BackgroundA minimally invasive step-up approach to necrotizing biliary pancreatitis often requires multiple interventions, delaying cholecystectomy. The risk of gallstone-related complications during this time interval is unknown, as is the feasibility and safety of cholecystectomy after minimally invasive step-up treatment. In this paper, we analyzed both. MethodsNecrotizing pancreatitis patients treated with a minimally invasive step-up approach who underwent interval cholecystectomy at 2 tertiary care centers between 2014 and 2019 were included. Gallstone-related complications prior to cholecystectomy were examined, as were surgical approaches to cholecystectomy and complications. Necrotizing pancreatitis patients treated without mechanical intervention were also examined. ResultsSeven of 31 patients developed gallstone-related complications between minimally invasive step-up treatment initiation and cholecystectomy. One patient developed biliary colic. Six patients developed acute cholecystitis. Two of these patients also developed choledocholithiasis, and 1 developed cholangitis, all requiring endoscopic retrograde cholangiopancreatography. Cholecystectomy was performed laparoscopically in 27 of 31 patients. One patient required open conversion, and 3 patients underwent planned cholecystectomy during another open operation. Four patients developed postoperative complications. Two of 14 necrotizing pancreatitis patients treated without mechanical intervention developed recurrent pancreatitis while awaiting cholecystectomy. ConclusionOver 20% of necrotizing pancreatitis patients treated by a minimally invasive step-up approach developed gallstone-related complications while awaiting cholecystectomy. Laparoscopic cholecystectomy is feasible and safe in the great majority of necrotizing pancreatitis patients treated by a minimally invasive step-up approach.

Novel techniques for management of portal system hemorrhage in acute pancreatitis

Current management of infected pancreatic necrosis is focused on a minimally invasive step-up approach. The step-up approach consists of initial percutaneous or endoscopic drainage of infected pancreatic necrosis, followed, if necessary, by minimally invasive surgical or endoscopic debridement. While there is reduced morbidity and mortality, vascular complications can be life-threatening. Reported vascular complications have been limited to arterial bleeding. Venous bleeding has not been previously reported. We present two cases of portal venous bleeding in patients who underwent treatment for infected pancreatic necrosis with a step-up approach. We discuss the clinical presentation, diagnosis, and initial management. Moreover, we present two different techniques that can be used to successfully manage venous bleeding in patients who have percutaneous drains in place as part of a step-up approach. These techniques involve tamponading the cavity or drain tract with topical hemostatics and direct embolization of the bleeding vein. These experiences can serve as a guide for managing portal venous bleeding in patients with infected pancreatic necrosis.

Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step-Up Approach: Comparison with a Modern Open Necrosectomy Cohort

A minimally invasive step-up (MIS) approach has been associated with reduced morbidity compared with open surgical necrosectomy (OSN) for treatment of necrotizing pancreatitis. We sought to determine whether transitioning from an OSN to an MIS-based approach would result in reduced mortality. MIS interventions included percutaneous drainage, endoscopic transgastric necrosectomy, video-assisted retroperitoneal debridement, sinus tract endoscopic necrosectomy, or a combination of techniques, with selective use of OSN. We conducted an observational cohort study with retrospective comparison at a single tertiary referral center (2006 through 2019). Eighty-eight patients were treated with OSN and 91 were treated with an MIS-based approach. Baseline characteristics and clinical outcomes were compared between groups. The primary end point was 90-day mortality. There was no difference in baseline characteristics. Ninety-day mortality was 2% with MIS compared with 10% with OSN (p= 0.03). One-year mortality was 3% with MIS compared with 15% with OSN (p= 0.012). The rate of organ failure was lower with MIS (30% vs 45%; p= 0.029), but there was a higher bleeding rate (19% vs 9%; p= 0.064). In the MIS group, 9% were treated with percutaneous drainage, 32% with endoscopic transgastric necrosectomy, 8% with video-assisted retroperitoneal debridement, 15% with sinus tract endoscopic necrosectomy, and 27% with a combination of techniques. Adoption of a multidisciplinary MIS-based approach to necrotizing pancreatitis resulted in a 5-fold decrease in mortality compared with OSN.

Minimally invasive step-up approach for the management of postoperative intraabdominal abscess after laparoscopic appendectomy.

Postoperative intraabdominal abscess (IAA) is the most feared complication after laparoscopic appendectomy (LA). We aimed to evaluate the management of this complication in a large cohort of patients undergoing LA in order to design a treatment algorithm. We included a consecutive series of patients undergoing LA for acute appendicitis from January 2008 to December 2018. The cohort of patients with postoperative IAA was divided into three groups based on the implemented treatments: G1: antibiotics only, G2: CT-guided drainage, and G3: laparoscopic lavage. Characteristics of the fluid collections and outcomes were analyzed in the three groups. A total of 1668 LA were performed; the rate of IAA was 2.2% (36 patients). There were 12 (33%) patients who received antibiotics only (G1), 8 (22%) underwent CT-guided percutaneous drainage (G2), and 16 (45%) underwent laparoscopic lavage (G3). The median size of the abscesses was 2.7 (1.2-4) cm in G1, 6.2 (4.5-8) cm in G2, and 9.6 (8-11.4) cm in G3 (p < 0.04). Patients with two or more fluid collections underwent a laparoscopic lavage in all cases. Treatment failure occurred in 16% (2/12), 12.5% (1/8) and 12.5% (2/16) of the patients in G1, G2, and G3, respectively. None of the patients in the entire cohort required open surgery to resolve the postoperative IAA. A minimally invasive step-up approach based on the size and number of fluid collections is associated with excellent outcomes. A treatment algorithm for post-appendectomy IAA is proposed.

Severe acute pancreatitis: eight fundamental steps revised according to the 'PANCREAS' acronym.

Severe acute pancreatitis remains a life-threatening condition, responsible for many disorders of homeostasis and organ dysfunction. By means of a mnemonic 'PANCREAS', eight important steps in the management of severe acute pancreatitis are highlighted. These steps follow the principle of goal-directed therapy and should be borne in mind after diagnosis and during clinical treatment. The first step is perfusion: the goal is to reach a central venous pressure of 12-15mmHg, urinary output 0.5-1ml/kg/hour and inferior vena cava collapse index greater than 48%. Next is analgesia: multimodal, systemic and combined pharmacological agent and epidural block are possibilities. Third is nutrition: precocity, enteral feeding in gastric or post-pyloric position. Parenteral nutrition works best in difficult cases to achieve the individual total caloric value. Fourth is clinical: mild, moderate or severe pancreatitis according to the Atlanta criteria. Radiology is fifth: abdominal computed tomography on the fourth day for prognosis or to modify management. Endoscopy is sixth: endoscopic retrograde cholangiopancreatography (cholangitis, unpredicted clinical course and ascending jaundice); management of pancreatic fluid collection and 'walled-off necrosis'. Antibiotics come next: infectious complications are common causes of morbidity. The only rational indication for antibiotics is documented pancreatic infection. The last step is surgery: the dogma is represented by the 'three Ds' (delay, drain, debride). The preferred method is a minimally invasive step-up approach, which allows for gradually more invasive procedures when the previous treatment fails.

Efficacy of minimally invasive step-up approach surgical interventions in patients with complicated acute necrotizing pancreatitis

Efficacy of minimally invasive step-up approach surgical interventions in patients with complicated acute necrotizing pancreatitis

Retroperitoneoscopic Debridement for Acute Necrotizing Pancreatitis

Abstract Introduction: The management of necrotizing pancreatitis with secondary infection has evolved from traditional open necrosectomy to a minimally invasive step-up approach, when feasible.1,2...

Surgical treatment of complicated pseudocyst of pancreas

Background: Total mortality of complicated pancreatic pseudocyst is 14%, postoperative - 11%, while complications such as sepsis, bleeding, perforation of the abdominal cavity, it is 40 - 60%. Methods: The work is based on retrospective and prospective analysis of the results of surgical treatment of 505 patients with pancreatic pseudocyst complicated, divided according to the classification D'Egidio A. and Schein M.(1991). With type I were 81, with type II were 247 and with type III were 177 patients. Used tactics Step-up approach for the treatment of all patients. Results: At the I type in 77.1% of patients used a percutaneous drainage under ultrasound and laparoscopy.In 32.9% performed open surgery. In the treatment of patients with type II in 119 (48.2%) completed mini-invasive surgery: ultrasound - percutaneous puncture and drainage under the ultrasound, endoscopic transgastric and transduodenum anastomosis. As the first stage 15 (6.07%) patients, complicated by bleeding in their cavity performed Х-ray occlusion of the vessel. Open surgery in patients with type II performed in 128 (51.8%). Were made external drainage (17.1%), internal drainage (76%) and resection methods (6.9%). In the treatment of type III mini-invasive interventions used in 36 (20.3%) patients. Internal drainage performed in 84 (47.4%), external drainage in 8 (4.5%), resection surgery in 46 (26%) patients. Total mortality was 0.79%. Conclusion: Our results indicate that the preferred treatment strategy is a minimally invasive Step-up approach.

Analysis of a Step-Up Approach Versus Primary Open Surgical Necrosectomy in the Management of Necrotizing Pancreatitis: Experience in a Cohort of Patients at a US Academic Medical Center.

An increasing number of providers have begun to use a minimally invasive step-up approach as opposed to traditional surgical necrosectomy in the management of acute necrotizing pancreatitis. Studies have shown mixed results, thus we hypothesized that the step-up approach is safer and associated with decreased mortality and length of stay (LOS). This is a retrospective cohort study of patients admitted from January 2010 to March 2015 who underwent interventions for walled-off pancreatic necrosis (WOPN). Primary outcomes included LOS after intervention and mortality, in-hospital and 90-day, with secondary outcomes of procedural complications. Sixty-nine patients developed WOPN requiring intervention during the study period. In-hospital mortality was 5.6% (n = 2) in the step-up cohort compared with 18.2% (n = 6) in the surgical cohort (relative risk, 3.27; 95% confidence interval, 0.71-15.09). Ninety-day mortality was 9.1% (n = 3) in the step-up cohort and 21.9% (n = 7) in the surgical cohort (relative risk, 2.41; 95% confidence interval, 0.68-8.50). Postintervention LOS was 8 days in the step-up cohort and 17 days in the surgical cohort (P = 0.62). A step-up approach, as compared with primary surgical necrosectomy in the management of WOPN, results in clinically significant decreases in mortality and LOS.

Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: Outcomes in a large cohort of patients

ObjectivesThe minimally invasive step-up approach for treatment of walled off necrosis (WON) involves drainage followed by later necrosectomy as needed, and is superior to primary surgical necrosectomy. Reported series of endoscopic transluminal necrosectomy include highly selected patients. We report outcomes of a large series of patients with WON managed by an algorithm based on an endoscopically centered step-up approach. MethodsConsecutive patients with necrotizing pancreatitis from 2009 to 2014, with intervention only for infected or persistently symptomatic WON. The primary approach involved endoscopic transluminal drainage plus minus necrosectomy whenever feasible, with percutaneous catheter drainage (PCD) plus minus sinus tract endoscopy if not feasible or sufficient. Surgery was reserved for failures of the step up approach. ResultsOf 109 consecutive patients with necrotizing pancreatitis, intervention was required in 83, including endoscopic transluminal drainage in 73 (88%) (alone in 49 and combined with PCD in 24), and PCD alone in 10 (12%). 64 (77%) of the 83 patients required endoscopic transluminal and/or sinus tract necrosectomy. Adverse events occurred in 11 (13%). Three patients (4%) failed step up approach and required open surgical necrosectomy. All-cause mortality occurred in 6 (7%) of 83 patients after intervention, including 2 of 3 requiring surgery. ConclusionsAn algorithm based step-up approach for interventions in necrotizing pancreatitis using primarily endoscopic techniques with adjunctive percutaneous approaches as needed resulted in favorable outcomes with small numbers proceeding to open surgery, and with acceptable rates of major complications and mortality. A purely endoscopic transluminal approach was feasible in approximately 60% of patients requiring intervention in this series.