V. Tam1, C. Umapathy4, M. Zenati3, S. Downs-Canner3, B. A. Boone1, J. Steve1, A. Zureikat1, K. K. Lee1, H. Zeh1, D. Yadav2, M. E. Hogg1 1University Of Pittsburgh,Surgical Oncology,Pittsburgh, PA, USA 2University Of Pittsburgh,Gastroenterology, Hepatology And Nutrition,Pittsburgh, PA, USA 3University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA 4University Of Pittsburgh,General Internal Medicine,Pittsburgh, PA, USA
Introduction:
Infected pancreatic necrosis is a highly morbid disease that was traditionally approached with an open necrosectomy. This approach was associated with rates of morbidity and mortality up to 95% and 39%, respectively. The multicenter randomized controlled PANTER trial published in 2010 in the New England Journal of Medicine proposed a “Step-Up” approach which demonstrated fewer major complications than conventional treatment, with comparable rates of mortality, and spared a major operation in one-third of patients. We sought to evaluate the practical adherence to the Step-Up approach at a single tertiary care institution, its temporal adoption into clinical practice, and impact on outcomes.
Methods:
This is a retrospective review of all patients treated at a tertiary care center with infected pancreatic necrosis between 2006 and 2014. Diagnosis was based on positive culture on pancreatic fine needle aspiration, or presence of an air filled necroma on computed tomography. “Modified Step-Up” (MSU) was defined as percutaneous or endoscopic drainage followed by additional percutaneous or endoscopic drainage, followed by any surgical intervention, including video-assisted retroperitoneal debridement and open necrosectomy. Patients were stratified into the “early” pre-PANTER (2006-2010) or ”late” post-PANTER (2010-2014) period. Rates of adherence to the MSU approach were compared as well as clinical outcomes.
Results:
There were 130 patients with infected necrotizing pancreatitis in the overall cohort; 75(58%) and 55(42%) were treated in the early and late period. At baseline, patients admitted in the late period were more likely to have higher ASA scores (3-5 vs 1-2, 92% vs 39%, p<0.001). In the late period, adherence to MSU was 46%(n=25) vs. 27%(n=27) in the early period (p<0.05). Late period patients had a greater likelihood of percutaneous drainage (65% vs. 43%, p=0.012) and greater number of total median interventions (3 vs. 2, p<0.001), however had comparable rates of surgery (73% vs. 79%, p=0.432), including 34(85%) open necrosectomies in the late period vs. 55(93%) in the early period. There were no differences in length of hospital stay, rates of in-hospital mortality, long-term complications, or survival at 2-years following discharge. Patients in the late period were less likely to have a pancreatitis-related readmission (47% vs. 71%, p=0.007) or multiple readmissions (31% vs. 51%, p=0.024).
Conclusion:
Overall, adherence to the MSU approach was 46% between 2010 and 2014. Patients treated during this period had lower rates of pancreatitis-related readmission and total readmissions, with similar rates of long-term complications and mortality compared to patients between 2006-2010. This study demonstrates that adoption of clinical guidelines can result in improved clinical outcomes. Barriers to implementation of the Step-Up approach should be identified to improve adherence rates.