Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis. Issue 8 (August 2019)

• Record Type: Journal Article
• Authors: Pickens, Ryan C.; Sulzer, Jesse K.; Cochran, Allyson; Vrochides, Dionisios; Martinie, John B.; Baker, Erin H.; Ocuin, Lee M.; Iannitti, David A.
• Is Part Of: American surgeon. Volume 85:Issue 8(2019)
• Page Start: 840
• Page End: 847
• Publication Date: 2019-08
• Subjects: Surgery -- Periodicals; Surgery -- United States -- Periodicals; 617.0973
• DOI: 10.1177/000313481908500834
• Languages: English
• ISSNs: 0003-1348

Abstract

The role of surgical intervention for necrotizing pancreatitis has evolved; however, no widely accepted algorithm has been established to guide timing and optimal modality in the minimally invasive era. This study aimed to retrospectively validate an established institutional timing- and physiologic-based algorithm constructed from evidence-based guidelines in a high-volume hepatopancreatobiliary center. Patients with necrotizing pancreatitis requiring early (≤six weeks from symptom onset) or delayed (>six weeks) surgical intervention were reviewed over a four-year period (n = 100). Early intervention was provided through laparoscopic drain-guided retroperitoneal debridement (n = 15) after failed percutaneous drainage unless they required an emergent laparotomy (due to abdominal compartment syndrome, bowel necrosis/perforation, or hemorrhage) after which conservative, sequential open necrosectomy was performed (n = 47). Robot-assisted (n = 16) versus laparoscopic (n = 22) transgastric cystgastrostomy for the delayed management of walled-off pancreatic necrosis was compared, including patient factors, operative characteristics, and 90-day clinical outcomes. Major complications after early debridement were similarly high (open 25% and drain-guided 27%), yet 90-day mortality was low (open 8.5% and drain-guided 7.1%). Patient and operative characteristics and 90-day outcomes were statistically similar for robotic versus laparoscopic transgastric cystogastrostomy. Our evidence-based algorithm provides a stepwise approach for the management of necrotizing pancreatitis, emphasizing minimally invasive early and late interventions when feasible with low morbidity and mortality. Robot-assisted transgastric cystogastrostomy is an acceptable alternative to a laparoscopic approach for the delayed treatment of walled-off pancreatic necrosis.