M. R. Driedger1, F. R. Sutherland1, E. Dixon1, S. Gregg1, N. Zyromski2, C. G. Ball1 1University Of Calgary,General Surgery,Calgary, AB, Canada 2Indiana University School Of Medicine,Indianapolis, IN, USA
Introduction:
Severe acute pancreatitis (SAP) occurs in 15% of patients with generalized pancreatitis. Walled off pancreatic necrosis (WOPN) is the most common end result of SAP. When symptomatic, WOPN requires intervention. The aim of this study was to evaluate the role of simultaneous cystgastostomy and necrosectomy (CG/N) for WOPN.
Methods:
A retrospective review of patients with WOPN undergoing surgical management on a high volume pancreatic service over 11 years (2005-2016) was performed. Outcomes included mortality, morbidity, intervention timing and symptom resolution. Statistics were descriptive.
Results:
Seventy-seven patients were analyzed (mean WOPN diameter=14.5 cm, 67.5% male, mean age=47 years). The majority were acutely ill, with an average preoperative length of stay of 28.7 days and 26% requiring preoperative support in the Intensive Care Unit (ICU). Preoperative complications were prevalent (42.9%), and included mesenteric vein thrombosis (37%), gastric outlet obstruction (19.2%), respiratory complications (19.2%), bacteremia (13.7%) and acute kidney injury (9.6%). Nearly all (93.5%) patients underwent an open trans-gastric CG/N while 6.5% received a cystjejunostomy. The median duration of time between the onset of SAP and operative intervention was 45.1 days. Forty-two percent of the cultured necrosum was infected with bacteria. Postoperative morbidity included infection (10.4%), bleeding (5.2%), fistula (5.2%) and re-operation (3.9%). Postoperative median hospital length of stay was 10 days (range 4-228) with 96.1% of patients discharged home. Mortality was 2.6% with 10.4% requiring postoperative ICU care. The mean length of follow up was 12 months with 87.7% of patients having complete clinical resolution of symptoms at an average of 7.3 weeks. Recurrent WOPN occurred in only 5.5% of patients at an average of 19 months after the index operation.
Conclusion:
Despite acutely ill and comorbid patients with large WOPN volumes, simultaneous CG/N offers a definitive single-stage solution in the vast majority of patients with minimal postoperative morbidity and rapid return to an asymptomatic state. Upon consideration of the minimal laparotomy required, this procedure represents the preferred approach for WOPN.