Is an Endoscopic Transluminal Approach Better Than Surgery for Patients With Necrotizing Pancreatitis?

An endoscopic transluminal approach for treatment of infected necrotizing pancreatitis, compared with minimally invasive surgery, significantly reduced major complications, lowered costs, and increased quality of life, according to a randomized trial published in the March issue of Gastroenterology.

Mean number of SIRS criteria over time after endoscopy (endo) vs surgery (surg).

Acute pancreatitis is the third most common gastrointestinal disorder in the United States, requiring more than 275,000 hospitalizations each year. Necrotizing pancreatitis occurs in 20% of patients with acute pancreatitis and leads to death in up to 39% of patients; infection of necrotic tissue can result in sepsis and organ failure. Infected necrotizing pancreatitis is usually treated by surgical necrosectomy, which is associated with high rates of adverse events (up to 95%) and death (up to 39%). Minimally invasive surgical techniques that incorporate percutaneous catheter placement with minimally invasive necrosectomy have been reported to have better outcomes than open surgical necrosectomy.

Endoscopy can be used for treatment of necrotic collections, with adverse events in as many as 25% of patients and less than 10% mortality. Endoscopic techniques include endoscopic ultrasound-guided transluminal drainage by creation of single or multiple tracts with placement of plastic or metal stents, concomitant placement of percutaneous drainage catheters, and mechanical debridement of the necrotic tissue via transluminal and/or percutaneous tracts using an endoscope. These techniques, when structured to the size and extent of the necrotic collection, appear to have better outcomes.

It is unclear whether minimally invasive surgery or endoscopy is better for treatment of necrotizing pancreatitis, based on clinical outcomes, quality of life, and costs. Ji Young Bang conducted a trial to directly compare the effects of minimally invasive surgery vs endoscopy in 66 patients with necrotizing pancreatitis.

In the study, patients were randomly assigned to groups that underwent minimally invasive surgery (laparoscopic or video-assisted retroperitoneal debridement, depending on location of collection) or an endoscopic step-up approach (transluminal drainage with or without necrosectomy). The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months of follow up.

The primary endpoint occurred in 11.8% of patients who received the endoscopic procedure and 40.6% of patients who received the minimally invasive surgery (risk ratio 0.29). Although there was no significant difference in mortality between groups, none of the patients who underwent endoscopy developed enteral or pancreatic-cutaneous fistulae, compared with 28.1% of the patients who underwent surgery.

The mean number of major complications per patient was significantly higher in the surgery group (0.69 ± 1.03) than the endoscopy group (0.15 ± 0.44).

At 72 hours after the procedure, a significantly lower porportion of patients in the endoscopy group had systemic inflammatory response syndrome (SIRS, 20.6%) compared with the surgery group (65.6%). Endoscopy resulted in early resolution of preexisting SIRS in 68.8% of patients (vs 18.8% for surgery) and a smaller proportion patients with new-onset SIRS (5.6% vs 56.3% for surgery) (see figure).

The physical health score for quality of life at 3 months was significantly better with the endoscopic approach and mean total cost was lower ($75,830 compared with $117,492 for surgery).

Bang et al conclude that endoscopy, compared with minimally invasive surgery, reduces major complications or death, mean number of major complications per patient, rate of disease-related adverse events, and costs, for patients with confirmed or suspected infected necrotizing pancreatitis.

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