Open necrosectomy in acute pancreatitis–obsolete or still useful?

Abstract

Background: Multiple organ failure and early surgery are associated with high morbimortality after open necrosectomy. Data are mostly derived from historical cohorts with early necrosectomy bereft of step-up treatment algorithm implementation. Thus, mostly circumstantial evidence suggests a better clinical course following miniinvasive surgical and endoscopic necrosectomy. We studied the results of open necrosectomy in a contemporary cohort of patients with complicated pancreatic necrosis treated at a tertiary center. Methods: A retrospective cohort study from a university teaching hospital. Results of 109 consecutive patients treated with open necrosectomy during a 12-year period are reported. Results: The overall 90-day mortality rate was 22.9%. The 90-day mortality rate was 10.6% if necrosectomy could be delayed until 4 weeks from symptom onset and the necrosis had become walled off on preoperative imaging. The risk factors for 90-day mortality were age over 60 years (OR 19.4), pre-existing co-morbidities (OR 16.9), necrosectomy within 4 weeks (OR 6.5), multiple organ failure (OR 12.2), white blood cell count over 23 × 10 9 (OR 21.4), and deterioration or prolonged organ failure as an indication for necrosectomy (OR 10.4). None or one of these risk factors was present in 52 patients (47.7% of all patients), and these patients had no mortality. Conclusion: Late open necrosectomy for walled-off necrosis has a low mortality risk. Open necrosectomy can be done without mortality in the absence of multiple risk factors for surgery.

Outcomes of Open, Laparoscopic, and Percutaneous Drainage of Infected Walled-Off Pancreatic Necrosis: A Nationwide Inpatient Sample Study

“…Similarly, a recent study by Husu et al showed that patients undergoing surgical necrosectomy for WOPN have a 90-day mortality rate of 10.6%, which is comparable to the mortality rate seen in this study [16]. While no study in review of the literature has been able to find a statistically significant mortality benefit when comparing the different forms of intervention for infected WOPN, these results echo prior studies in that open necrosectomy is associated with a mortality rate of around 10% and that there may be evidence for improved survival with the use of MIS.…”

Spontaneous Free Peritoneal Perforation of an Infected Pancreatic Fluid Collection Managed with Laparoscopic Drainage and Necrosectomy

“…Percutaneous image-guided drains are initially placed followed by retroperitoneoscopic debridement. If all these minimal invasive methods fail, the last resort would be an open necrosectomy, which carries high morbidity and mortality rates [10,11]. This step-up approach was developed over several decades 2…”

Open necrosectomy is feasible as a last resort in selected cases with infected pancreatic necrosis: a case series and systematic literature review

“…Despite its employment for selected cases, in the clinical practice, as demonstrated by this review, this approach is still characterized by high rates of complications (34 to 95%) and death (11 to 39%) and with a risk of long-term pancreatic insufficiency [14]. Husu et al [27] declare that mortality after ON depends on patient's preoperative risk factors. According to their experience, patients with an average age over 60 years, with preoperative significant comorbidities, necrosectomy within 4 weeks from the clinical onset, and deterioration or prolonged organ failure, apparently seem to report a higher mortality rate.…”

“…Finally, a total of 20 studies were included in the systematic review [12,14,[27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44].…”