Endoscopic Treatment Superior to Surgical for Infected Pancreatic Necrosis.

In a small, randomized trial, endoscopic necrosectomy reduced interleukin-6 levels and resulted in much lower rates of major complications.

Infected pancreatic necrosis is one of the most serious complications of severe necrotizing pancreatitis. In the past, identification of infected necrosis led to immediate open debridement, with high mortality and morbidity. Now, these patients are often managed with targeted antibiotics, watchful waiting, and less-invasive procedures, including minimally invasive laparoscopic or retroperitoneal surgical debridement, percutaneous drainage and debridement, and endoscopic transgastric necrosectomy. However, whether one minimally invasive technique is better than another is unknown.

To compare outcomes of endoscopic versus surgical treatments, 22 patients with infected pancreatic necrosis were randomized to receive endoscopic transgastric necrosectomy or surgical necrosectomy in a multicenter trial. Surgical necrosectomy involved a video-assisted retroperitoneal debridement utilizing a laparoscope, a procedure previously shown to be superior to traditional open laparotomy.Endoscopic necrosectomy involved transgastric puncture of the walled-off necrosis with endoscopic ultrasound guidance, balloon dilation, and placement of 2 plastic stents and a nasocystic catheter. Irrigation through the catheter was performed for 24 hours with 1 L of normal saline, followed by dilation of the site to allow passage of a standard forward-viewing endoscope into the cavity to evacuate necrotic tissue. The procedure was repeated until the majority of the necrotic material was removed. All patients were treated with antibiotics. The primary endpoint was the proinflammatory response after necrosectomy, measured by serum interleukin (IL)-6 levels. Secondary endpoints were major complications and death.

In the surgical group, 6 of the 10 patients who completed the procedure underwent video-assisted retroperitoneal debridement only, and 4 required laparotomy. In the endoscopy group, all 10 patients underwent transgastric necrosectomy and required a median of three procedures. IL-6 levels increased after surgical necrosectomy and decreased after endoscopic necrosectomy (P=0.004). At 6 months follow-up, patients in the endoscopy group versus the surgery group experienced fewer major complications or death (20% vs. 80%; P=0.03), including fewer incidences of new-onset major organ failure (0% vs. 50%), pancreatic fistula (10% vs. 70%), and the need for pancreatic enzyme replacement (0% vs. 50%). One endoscopy patient and four surgery patients died.

Comment: In this first study to compare two minimally invasive approaches to managing infected pancreatic necrosis, endoscopic necrosectomy reduced the proinflammatory response and resulted in lower mortality or major complications compared with surgical necrosectomy. Although initially planned as minimally invasive, the surgical approach required frequent conversion to an open procedure, which might explain the large differences in complications. Despite its small size, this study highlights the differences in outcomes between groups and reinforces the increasingly prominent role that endoscopic techniques are playing in the management of severe and necrotizing pancreatitis.

Source:  Journal Watch Gastroenterology

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