gms | German Medical Science

Introduction: Recent publications have suggested a “step-up” approach is favored for the treatment of acute necrotizing pancreatitis. The aim of this study was to evaluate the outcome of minimal invasive procedures for necrosectomy in acute pancreatitis.

Material and methods: Patients with acute pancreatitis admitted to our institution from 2001 to 2010 (n>500) were identified by ICD and OPS codes of the electronic patient data files. From these, patients who received minimal invasive procedures (minimal invasive necrosectomy (MINE) and endoscopic transgastric drainage (ETG)) were selected for analysis. Statistical analysis employed two-sided Fisher’s exact test and Mann-Whittney U-test of the SPSS 17.0 software.

Results: From 2002 to 2009, n=32 patients were treated by minimal invasive procedures at our institution. Around 80% of cases constituted the first episode of an acute necrotizing pancreatitis. Procedures performed were 15 MINE and 17 ETG of pancreatic necrosis or walled off pancreatic necrosis. Time from start of symptoms to intervention was shorter for MINE than ETG (median, 4 vs 8 weeks, p<0.05) and therefore, the rate of citically ill patients with sepsis or septic shock was higher in MINE (73% vs 13%, p<0.05). Problems after MINE (vs ETG) were ongoing sepsis (13% vs 6%), bleeding requiring intervention (27% vs 12%) and pancreatic fistula (7% vs 0%). One specific complication of ETG was gastric perforation to the peritoneal cavity during the procedure (30% vs 0% with MINE), requiring immediate open pseudocystogastrostomy. Laparotomy was necessary in 27% after MINE and 41% after ETG, due to specific complications or persistent infected necrosis. Overall Mortality was higher after MINE vs ETG (27% vs 6%, p=0.16).

Conclusion: Morbidity and mortality remains high in acute necrotizing pancreatitis. Operative procedures should be delayed as long as possible to reduce mortality. Minimal invasive procedures can avoid the necessity of laparotomy but also bear specific complications requiring immediate or secondary open operative treatment. They should therefore only be performed at specialized centers.