Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach

Minimal access retroperitoneal pancreatic necrosectomy for infected pancreatic necrosis: A single-center of 15 years' experience

BACKGROUND

Minimal access retroperitoneal pancreatic necrosectomy stands as an effective treatment method for infected pancreatic necrosis. However, its popularity still needs to be improved, and in-depth exploration are needed regarding its indications, complications and efficacy. Therefore, we sought to explore the technical details of minimal access retroperitoneal pancreatic necrosectomy surgery and evaluate its safety and efficacy.

METHODS

A retrospective analysis was performed in a prospective maintained database of infected pancreatic necrosis between January 2010 and April 2024 at a large Chinese tertiary hospital.

RESULTS

Of 400 patients with infected pancreatic necrosis, 18.8% (75/400) received only percutaneous catheter drainage, 61.2% (245/400) underwent a minimal-access retroperitoneal pancreatic necrosectomy approach, and 20% (80/400) adopted open pancreatic necrosectomy. The number of patients with infected pancreatic necrosis treated with the minimal access retroperitoneal pancreatic necrosectomy procedure has steadily increased over the past decade, accompanied by a decreasing trend in both the mortality and a composite of major complications or death. Minimal access retroperitoneal pancreatic necrosectomy was associated with a lower incidence of gastrointestinal fistula (33 [13.5%] vs 24 [30%], P < .001), mortality (44 [18%] vs 30 [37.5%], P < .001), and composite of major complications or death (88 [35.9%] vs 46 [57.5%], P < .001) compared with open pancreatic necrosectomy. In total, 6.9% (17/245) of patients in the minimal access retroperitoneal pancreatic necrosectomy group required conversion to open pancreatic necrosectomy due to uncontrolled infection or severe complications, whereas 30% (24/80) of patients in the open pancreatic necrosectomy group needed subsequent minimal access retroperitoneal pancreatic necrosectomy to remove residual necrotic tissue and address evolving necrosis. Multivariate analysis of risk factors of conversion to open pancreatic necrosectomy or death indicated that critical acute pancreatitis (odds ratio, 6.1; 95% confidence interval, 1.8-20.7, P = .004), multiple organ failure (odds ratio, 39.7; 95% confidence interval, 4.1-380.6, P < .001), bloodstream infection (odds ratio, 1.1; 95% confidence interval, 1.1-2.8, P = .007), and hemorrhage (odds ratio, 45; 95% confidence interval, 4.4-457.5, P = .004) were significant factors.

CONCLUSION

Minimal access retroperitoneal pancreatic necrosectomy is a safe and effective approach for improving the prognosis of patients with infected pancreatic necrosis. Standardized surgical procedures, meticulous technical execution, and individualized management are essential for optimizing the efficacy of minimal access retroperitoneal pancreatic necrosectomy.

Efficiency of laparoscopic retroperitoneal pancreatic necrosectomy for treating infected pancreatic necrosis with duodenal fistula: a single-center retrospective cohort study

BACKGROUND

Open surgical debridement was the main treatment option for infected pancreatic necrosis (IPN). However, it was associated with significant trauma, leading to a higher mortality rate. With the development of minimally invasive surgery, the step-up treatment principle centered around minimally invasive intervention, significantly reducing the incidence of complications and mortality rates among IPN patients. However, few studies have reported the efficacy of laparoscopic retroperitoneal pancreatic necrosectomy (LRPN), a new minimally invasive debridement technique, in IPN patients with duodenal fistula (DF)-a severe complication of IPN. Therefore, we analyzed the effectiveness and safety of LRPN for treating IPN with DF and discussed the impact of DF on patient prognosis.

METHODS

We retrospectively examined patients diagnosed with IPN between 2018 and 2023. The patients were divided into two groups based on the presence or absence of DF. Clinical characteristics, treatment strategies, clinical outcomes, and follow-up information were analyzed. A 1:1 propensity score-matching (PSM) method was used to assess differences in outcome indicators more accurately.

RESULTS

A total of 197 patients were examined. After PSM, no significant differences were observed between the two groups in in-hospital mortality rate, incidence of single organ failure, rate of postoperative severe complications (Clavien-Dindo Classification ≥ 3), and intensive care unit stay (P > 0.05). However, the incidence of multiorgan failure, gastrointestinal bleeding, number of percutaneous catheter drainage (PCD) procedures, surgery cases, hospital stay, and hospitalization costs were higher in the DF group (P < 0.05). Of these patients, 71.6% (n = 141) were treated with PCD + LRPN, with a conversion rate of 6.38% to open surgery. A higher proportion of patients in the non-DF group showed improved clinical outcomes solely with PCD (22.6% vs. 2.4%, P < 0.05), whereas a higher proportion of patients in the DF group underwent PCD + LRPN (88.1% vs. 67.1%, P < 0.05). Both groups showed a significant reduction in the Sequential Organ Failure Assessment score 72 h postoperatively.

CONCLUSIONS

For patients with IPN and DF, the LRPN-centered step-up strategy was safe and effective. DF prolongs hospital stay and increases hospitalization costs for patients.

Step-Up versus Open Approach in the Treatment of Acute Necrotizing Pancreatitis: A Case-Matched Analysis of Clinical Outcomes and Long-Term Pancreatic Sufficiency

Background/Objectives: Acute necrotizing pancreatitis (ANP) with secondary infection of necrotic tissue is associated with a high rate of complications and mortality. The optimal approach is still debatable, but the minimally invasive modality has gained great attention in the last decade as it follows the principle of applying minimal surgical trauma to achieve a satisfying therapeutic objective. We compared clinical outcomes between the step-up approach (SUA) and open necrosectomy (ON) in the treatment of acute necrotizing pancreatitis. Methods: A prospective cohort study over the period of 2011-2021 in a university teaching hospital was performed. Results of 99 consecutive patients with ANP who required surgical/radiological intervention were collected. A case match analysis (2:1) was performed, and the final groups comprised 40 patients in the OA group and 20 patients in the SUA group. Demographic, clinicopathologic, and treatment data were reviewed. Results: Baseline characteristics and disease severity were comparable between the two groups. The patients from the SUA group had a significantly lower morbidity rate and rate of pancreatic insufficiency. Death occurred in 4 of 20 patients (20%) in the SUA group and in 11 of 40 patients (27.5%) in the ON group (risk ratio with the step-up approach, 0.72; 95% confidence interval, 0.26 to 1.99; p = 0.53). Conclusions: A minimally invasive step-up approach provides comparable outcomes to open necrosectomy in the treatment of ANP with infected pancreatic necrosis. While mortality and hospital stay were comparable between the groups, morbidity and pancreatic insufficiency were significantly lower in the SUA group. Further studies on a larger number of patients are required to define the place of SUA in the modern treatment of ANP.

One-step laparoscopic pancreatic necrosectomy verse surgical step-up approach for infected pancreatic necrosis: a case-control study

BACKGROUND

The surgical step-up approach often requires multiple debridements and might not be suitable for infected pancreatic necrosis (IPN) patients with various abscesses or no safe route for percutaneous catheter drainage (PCD). This case-control study aimed to investigate the safety and effectiveness of one-step laparoscopic pancreatic necrosectomy (LPN) in treating IPN.

METHODS

This case-control study included IPN patients undergoing one-step LPN or surgical step-up in our center from January 2015 to December 2020. The short-term and long-term complications after surgery, length of hospital stay, and postoperative ICU stays in both groups were analyzed. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of major complications or death.

RESULTS

A total of 53 IPN patients underwent one-step LPN and 37 IPN patients underwent surgical step-up approach in this study. There was no significant difference in the incidence of death, major complications, new-onset diabetes, or new-onset pancreatic exocrine insufficiency between the two groups. However, the length of hospital stay in the one-step LPN group was significantly shorter than that in the surgical step-up group. Univariate regression analysis showed that the surgical approach (one-step/step-up) was not the risk factor for major complications or death. Multivariate logistic regression analysis indicated that computed tomography (CT) severity index, American Society of Anesthesiologists (ASA) class IV, and white blood cell (WBC) were the significant risk factors for major complications or death.

CONCLUSION

One-step LPN is as safe and effective as the surgical step-up approach for treating IPN patients, and reduces total hospital stay.