Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach

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.

One-step laparoscopic pancreatic necrosectomy verse surgical step-up approach for infected pancreatic necrosis: a case-control study

BACKGROUND

The surgical step-up approach often requires multiple debridements and might not be suitable for infected pancreatic necrosis (IPN) patients with various abscesses or no safe route for percutaneous catheter drainage (PCD). This case-control study aimed to investigate the safety and effectiveness of one-step laparoscopic pancreatic necrosectomy (LPN) in treating IPN.

METHODS

This case-control study included IPN patients undergoing one-step LPN or surgical step-up in our center from January 2015 to December 2020. The short-term and long-term complications after surgery, length of hospital stay, and postoperative ICU stays in both groups were analyzed. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of major complications or death.

RESULTS

A total of 53 IPN patients underwent one-step LPN and 37 IPN patients underwent surgical step-up approach in this study. There was no significant difference in the incidence of death, major complications, new-onset diabetes, or new-onset pancreatic exocrine insufficiency between the two groups. However, the length of hospital stay in the one-step LPN group was significantly shorter than that in the surgical step-up group. Univariate regression analysis showed that the surgical approach (one-step/step-up) was not the risk factor for major complications or death. Multivariate logistic regression analysis indicated that computed tomography (CT) severity index, American Society of Anesthesiologists (ASA) class IV, and white blood cell (WBC) were the significant risk factors for major complications or death.

CONCLUSION

One-step LPN is as safe and effective as the surgical step-up approach for treating IPN patients, and reduces total hospital stay.