Subscribe to RSS
DOI: 10.1055/a-1994-6214
Safety of endoscopic pancreatic necrosectomy compared with percutaneous and surgical necrosectomy: a nationwide inpatient study
Abstract
Background and study aims Pancreatic necrosis is an independent predictor of morbidity and mortality among patients with acute pancreatitis. We compared the safety and outcomes of three techniques including endoscopic necrosectomy, fluoroscopy-guided percutaneous necrosectomy by an interventional radiologist, and surgical necrosectomy.
Patients and methods Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent pancreatic necrosectomy from 2016 to 2019. They were identified using the International Classification of Diseases, 10th Revision, Procedure Coding System.
Results: Of the 2,281 patients meeting the selection criteria, the method of pancreatic necrosectomy was as follows: endoscopy (n = 672), percutaneous (n = 1,338), and surgery (n = 271). Compared to surgery, the rate of mortality was lowest for endoscopy (hazard ratio (HR) 0.27; 95 % CI 0.08–0.90; P = 0.033) followed by percutaneous (HR 0.44; 95 % CI, 0.20–0.98; P = 0.045). Endoscopy was associated with less post-procedure bleeding compared to percutaneous and surgical necrosectomy (P < 0.001), as well as lower rates of post-procedure renal failure (P < 0.001) and respiratory failure (P = 0.002). Endoscopy was associated with average shorter lengths of stay and total hospital costs when compared with percutaneous and surgical approaches, respectively (20.1 vs 25.8 vs 38.3 days; P < 0.001) and ($ 57K vs $ 76K vs $ 123K; P < 0.001).
Conclusions Endoscopic necrosectomy is associated with significantly lower risk of inpatient mortality, adverse events, length of stay, and cost when compared to percutaneous and surgical approaches.
Publication History
Received: 11 October 2022
Accepted after revision: 06 December 2022
Accepted Manuscript online:
07 December 2022
Article published online:
04 April 2023
© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
-
References
- 1 Shaheen NJ, Hansen RA, Morgan DR. et al. The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol 2006; 101: 2128-2138
- 2 Fagenholz PJ, Fernández-del Castillo C, Harris NS. et al. Direct medical costs of acute pancreatitis hospitalizations in the United States. Pancreas 2007; 35: 302-307
- 3 Beger HG, Rau B, Mayer J. et al. Natural course of acute pancreatitis. World J Surg 1997; 21: 130-135
- 4 Banks PA, Freeman ML. Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006; 101: 2379-2400
- 5 Baron TH, DiMaio CJ, Wang AY. et al. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology 2020; 158: 67-75.e1
- 6 Traverso LW, Kozarek RA. Pancreatic necrosectomy: definitions and technique. J Gastrointest Surg 2005; 9: 436-439
- 7 Tsiotos GG, Luque-de León E, Sarr MG. Long-term outcome of necrotizing pancreatitis treated by necrosectomy. Br J Surg 1998; 85: 1650-1653
- 8 Rau B, Bothe A, Beger HG. Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series. Surgery 2005; 138: 28-39
- 9 Connor S, Alexakis N, Raraty MG. et al. Early and late complications after pancreatic necrosectomy. Surgery 2005; 137: 499-505
- 10 Howard TJ, Patel JB, Zyromski N. et al. Declining morbidity and mortality rates in the surgical management of pancreatic necrosis. J Gastrointest Surg 2007; 11: 43-49
- 11 Haghshenasskashani A, Laurence JM, Kwan V. et al. Endoscopic necrosectomy of pancreatic necrosis: a systematic review. Surg Endosc 2011; 25: 3724-3730
- 12 Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13: e1-e15
- 13 Arvanitakis M, Dumonceau JM, Albert J. et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy 2018; 50: 524-546
- 14 Ramai D, Enofe I, Deliwala SS. et al. Early (<4 Weeks) Versus Standard (≥ 4 Weeks) Endoscopic Drainage of Pancreatic Walled-Off Fluid Collections: A Systematic Review and Meta-analysis [published online ahead of print, 2022 Nov 14]. Gastrointest Endosc 2022;
- 15 Onnekink AM, Boxhoorn L, Timmerhuis HC. et al. Endoscopic Versus Surgical Step-Up Approach for Infected Necrotizing Pancreatitis (ExTENSION): long-term follow-up of a randomized trial. Gastroenterology 2022; 163: 712-722.e14
- 16 van Santvoort HC, Besselink MG, Bakker OJ. et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010; 362: 1491-1502
- 17 van Brunschot S, van Grinsven J, van Santvoort HC. et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391: 51-58
- 18 Hollemans RA, Bakker OJ, Boermeester MA. et al. Superiority of step-up approach vs open necrosectomy in long-term follow-up of patients with necrotizing pancreatitis. Gastroenterology 2019; 156: 1016-1026
- 19 Ricci C, Pagano N, Ingaldi C. et al. Treatment for infected pancreatic necrosis should be delayed, possibly avoiding an open surgical approach: a systematic review and network meta-analysis. Ann Surg 2021; 273: 251-257
- 20 HCUP Nationwide Readmissions Database (NRD). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality; 2019 https://www.hcup-us.ahrq.gov/nrdoverview.jsp
- 21 Moore BJ, White S, Washington R. et al. Identifying increased risk of readmission and in-hospital mortality using hospital administrative data: The AHRQ Elixhauser Comorbidity index. Med Care 2017; 55: 698-705
- 22 Quan H, Sundararajan V, Halfon P. et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005; 43: 1130-1139
- 23 van Walraven C, Austin PC, Jennings A. et al. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Med Care 2009; 47: 626-633
- 24 Li C. Little’s test of missing completely at random. Stata J 2013; 13: 795-809
- 25 Royston P. Multiple imputation of missing values. Stata J 2004; 4: 227-241
- 26 Saunders R, Hughes FE, Evans JC. et al. Cost analysis and outcomes of endoscopic, minimal access and open pancreatic necrosectomy. Ann Surg Open 2021; 2: e068
- 27 Bang JY, Arnoletti JP, Holt BA. et al. An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis. Gastroenterology 2019; 156: 1027-1040
- 28 Mohamadnejad M, Anushiravani A, Kasaeian A. et al. Endoscopic or surgical treatment for necrotizing pancreatitis: Comprehensive systematic review and meta-analysis. Endosc Int Open 2022; 10: E420-E428
- 29 Khan MA, Hammad T, Khan Z. Endoscopic versus percutaneous management for symptomatic pancreatic fluid collections: a systematic review and meta-analysis. Endosc Int Open 2018; 6: E474-E483
- 30 Prasath V, Quinn PL, Oliver JB. et al. Cost-effectiveness analysis of infected necrotizing pancreatitis management in an academic setting. Pancreatology 2022; 22: 185-193