Journal Article

Retrospective Validation of an Algorithmic Treatment Pathway for Necrotizing Pancreatitis

Martinie, John B., Sulzer, Jesse K., Vrochides, Dionisios, Ocuin, Lee M., Pickens, Ryan C., Baker, Erin H., Iannitti, David A., Cochran, Allyson

2019

Overview

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.

• Publisher: SAGE Publications,SAGE PUBLICATIONS, INC
• Subject: Abdomen / Adult / Algorithms / Cholecystectomy / Classification / Clinical outcomes / Compartment syndrome / Complications / Cystotomy - methods / Cystotomy - statistics & numerical data / Cysts / Debridement - adverse effects / Debridement - methods / Drainage - mortality / Drainage - statistics & numerical data / Endoscopy / Evidence-Based Medicine / Female / Gastroenterology / Gastrostomy - methods / Gastrostomy - statistics & numerical data / Hemorrhage / Humans / Intervention / Intestine / Laparoscopy / Laparoscopy - adverse effects / Laparoscopy - statistics & numerical data / Male / Middle Aged / Morbidity / Mortality / Necrosis / Pancreas / Pancreatitis / Pancreatitis, Acute Necrotizing - mortality / Pancreatitis, Acute Necrotizing - pathology / Pancreatitis, Acute Necrotizing - surgery / Patients / Perforation / Practice Guidelines as Topic / Retrospective Studies / Robotic surgery / Robotic Surgical Procedures - adverse effects / Robotic Surgical Procedures - statistics & numerical data / Robotics / Robots / Statistical analysis / Time-to-Treatment / Trauma / Treatment Outcome / Working groups