M. M. Dua1, D. J. Worhunsky1, L. Malhotra1, W. G. Park1, J. A. Norton1, G. A. Poultsides1, B. C. Visser1 1Stanford University,Palo Alto, CA, USA
Introduction: The best operative strategy for necrotizing pancreatitis remains controversial. Traditional surgical necrosectomy is associated with significant morbidity; operative debridement contributes to the substantial risk of pancreatic
and bowel fistulae, which are associated with recurrent hospitalizations and long-term support to manage pain or nutritional requirements. Minimally invasive endoscopic and percutaneous strategies typically require multiple procedures and a prolonged hospital course. We developed a transgastric approach to pancreatic necrosectomy to overcome the shortcomings of the other techniques described.
Methods: Patients with walled-off, retrogastric pancreatic necrosis who underwent transgastric necrosectomy (TN) during 2009-2016 were retrospectively reviewed. Open TN is performed via an anterior gastrotomy to debride the pancreas through a wide cystgastrostomy in the posterior wall. Laparoscopic TN involves endoscopic insufflation of the stomach for placement of transgastric ports for operative debridement. The cystgastrostomy is left open in both types of TN to allow ongoing internal drainage of necrosis. Endpoints included postoperative complications and mortality.
Results: Forty-four patients underwent TN (9 open, 35 laparoscopic). Operative indications included persistent unwellness (n=26), infection (n=14), pseudoaneurysm hemorrhage failing embolization (n=3), and worsening sepsis (n=1). The median peroperative APACHE II score for the total cohort was 6 (0-27); however, disease severity was higher in the open TN group compared to the laparoscopic TN group (APACHE II score 12 vs 5, p = 0.03) resulting in a longer length of stay (LOS 11 vs 7 days, open vs laparoscopic, respectively, p = 0.01). Clinical outcomes for the total cohort are represented in the attached table. A majority of the cohort (74%) experienced none (n=23) or minor (n=10) complications. Six patients had postoperative bleeding; 5 required embolization and there was one death. No patient required more than one operative debridement; five patients required percutaneous drainage for residual collections. There were no postoperative fistulae or wound complications.
Conclusion: The transgastric approach to pancreatic necrosectomy allows for effective debridement with a single definitive operation and minimizes the morbidity associated with prolonged drainage, fistulae and wound complications. When anatomically suitable, the transgastric approach (whether laparoscopic or open) is an effective strategy that expedites return to pre-pancreatitis health and offers significant benefits in the recovery of these patients.
