What's Behind it All: A Retrospective Cohort Study of Retrograstric Pancreatic Necrosis Management.

OBJECTIVE

To compare outcomes of laparoscopic transgastric necrosectomy (LTN) and direct endoscopic necrosectomy (DEN) in the management of retrogastric walled-off necrosis.

BACKGROUND

Surgical and endoscopic transgastric approaches are used to manage retrogastric pancreatic necrosis. Studies comparing these treatment modalities are lacking but would influence contemporary practice patterns.

METHODS

LTN-treated or DEN-treated patients at Stanford University Hospital between 2011 and 2023 were identified. Cohort data included demographics, core pancreatitis care benchmarks, and clinical outcomes (total debridement time, new-onset endocrine, and exocrine pancreatic insufficiency) as well as reintervention, 30-day readmission, complication, and mortality rates. Long-term follow-up was also compared between intervention arms. Multivariable linear regression was used to assess the interaction between admission Acute Physiology and Chronic Health Evaluation II (APACHE-II) score and intervention on length of stay (LOS).

RESULTS

One hundred six patients (62% LTN and 38% DEN) were identified. Demographic and core pancreatitis benchmark data were similar between cohorts. Thirty-day readmission, complication, and mortality rates for surgical and endoscopic approaches were also similar: 23% versus 25% ( P = 0.98), 42% versus 40% ( P = 0.97), and 3% versus 3% ( P > 0.99). Median LTN total debridement time (minutes) was 131 versus 134 for DEN; however, complete debridement was achieved with only 1 LTN compared with 3 DENs ( P < 0.01). Although not statistically significant, LOS and unplanned intervention rates were less for LTN (8 vs 10 days, P = 0.41 and 6% vs 15%, P = 0.24). Multivariable analysis revealed a significant interaction between APACHE-II scores and LOS for LTN compared with DEN, which translated into a LOS reduction for higher APACHE-II scoring patients ( P = 0.02).

CONCLUSIONS

LTN is a safe and efficient treatment modality for walled-off necrosis, and compared with DEN, can reduce the LOS in high APACHE-II score patients. While additional comparative research between the two intervention types is needed, this study supports the role of a surgical approach in the management of retrogastric pancreatic necrosis.