Endoscopic Transgastric vs Surgical Necrosectomy for Infected Necrotizing Pancreatitis

TLDR

Infected necrotizing pancreatitis commonly requires necrosectomy, but surgical necrosectomy provokes a proinflammatory response and carries a high complication rate. The study aimed to compare the proinflammatory response and clinical outcomes of endoscopic transgastric versus surgical necrosectomy. Patients with infected necrotizing pancreatitis and an indication for intervention were randomized to endoscopic transgastric necrosectomy—transgastric puncture, balloon dilation, retroperitoneal drainage, and necrosectomy—or to surgical necrosectomy via video‑assisted retroperitoneal debridement or laparotomy. Endoscopic transgastric necrosectomy reduced post‑procedural IL‑6 levels, lowered the composite clinical endpoint (20% vs 80%), prevented new‑onset multiple organ failure, and decreased pancreatic fistulas compared with surgical necrosectomy. Trial registered at isrctn.org (ISRCTN07091918).

Abstract

Most patients with infected necrotizing pancreatitis require necrosectomy. Surgical necrosectomy induces a proinflammatory response and is associated with a high complication rate. Endoscopic transgastric necrosectomy, a form of natural orifice transluminal endoscopic surgery, may reduce the proinflammatory response and reduce complications.To compare the proinflammatory response and clinical outcome of endoscopic transgastric and surgical necrosectomy.Randomized controlled assessor-blinded clinical trial in 3 academic hospitals and 1 regional teaching hospital in The Netherlands between August 20, 2008, and March 3, 2010. Patients had signs of infected necrotizing pancreatitis and an indication for intervention.Random allocation to endoscopic transgastric or surgical necrosectomy. Endoscopic necrosectomy consisted of transgastric puncture, balloon dilatation, retroperitoneal drainage, and necrosectomy. Surgical necrosectomy consisted of video-assisted retroperitoneal debridement or, if not feasible, laparotomy.The primary end point was the postprocedural proinflammatory response as measured by serum interleukin 6 (IL-6) levels. Secondary clinical end points included a predefined composite end point of major complications (new-onset multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, or pancreatic fistula) or death.We randomized 22 patients, 2 of whom did not undergo necrosectomy following percutaneous catheter drainage and could not be analyzed for the primary end point. Endoscopic transgastric necrosectomy reduced the postprocedural IL-6 levels compared with surgical necrosectomy (P = .004). The composite clinical end point occurred less often after endoscopic necrosectomy (20% vs 80%; risk difference [RD], 0.60; 95% CI, 0.16-0.80; P = .03). Endoscopic necrosectomy did not cause new-onset multiple organ failure (0% vs 50%, RD, 0.50; 95% CI, 0.12-0.76; P = .03) and reduced the number of pancreatic fistulas (10% vs 70%; RD, 0.60; 95% CI, 0.17-0.81; P = .02). In patients with infected necrotizing pancreatitis, endoscopic necrosectomy reduced the proinflammatory response as well as the composite clinical end point compared with surgical necrosectomy.isrctn.org Identifier: ISRCTN07091918.