One-step laparoscopic pancreatic necrosectomy verse surgical step-up approach for infected pancreatic necrosis: a case-control study

doi:10.5847/wjem.j.1920-8642.2022.058

Abstract

Abstract:

BACKGROUND: The surgical step-up approach often requires multiple debridements and might not be suitable for infected pancreatic necrosis (IPN) patients with various abscesses or no safe route for percutaneous catheter drainage (PCD). This case-control study aimed to investigate the safety and effectiveness of one-step laparoscopic pancreatic necrosectomy (LPN) in treating IPN.

METHODS: This case-control study included IPN patients undergoing one-step LPN or surgical step-up in our center from January 2015 to December 2020. The short-term and long-term complications after surgery, length of hospital stay, and postoperative ICU stays in both groups were analyzed. Univariate and multivariate logistic regression analyses were performed to explore the risk factors of major complications or death.

RESULTS: A total of 53 IPN patients underwent one-step LPN and 37 IPN patients underwent surgical step-up approach in this study. There was no significant difference in the incidence of death, major complications, new-onset diabetes, or new-onset pancreatic exocrine insufficiency between the two groups. However, the length of hospital stay in the one-step LPN group was significantly shorter than that in the surgical step-up group. Univariate regression analysis showed that the surgical approach (one-step/step-up) was not the risk factor for major complications or death. Multivariate logistic regression analysis indicated that computed tomography (CT) severity index, American Society of Anesthesiologists (ASA) class IV, and white blood cell (WBC) were the significant risk factors for major complications or death.

CONCLUSION: One-step LPN is as safe and effective as the surgical step-up approach for treating IPN patients, and reduces total hospital stay.

Key words: Infected pancreatic necrosis, One-step laparoscopic pancreatic necrosectomy, Surgical step-up approach

Sheng-bo Han, Jin-huang Chen, Ping Hu, Ding Chen, Qing-yong Chen, Hai Zheng, Peng Xu, Chun-you Wang, Gang Zhao. One-step laparoscopic pancreatic necrosectomy verse surgical step-up approach for infected pancreatic necrosis: a case-control study[J]. World Journal of Emergency Medicine, 2022, 13(4): 274-282.

Figures/Tables 5

Figure 1.

Table 1.

Baseline characteristics of the patients

Variables	One-step LPN group (n = 53)	Surgical step-up group (n = 37)	P-value
Gender			0.705
Female	19 (35.8)	11 (29.7)
Male	34 (64.2)	26 (70.3)
Age, years	47.5±11.8	48.1±10.3	0.208
BMI, kg/m²	26.3±4.4	26.8±3.7	0.423
Cause of pancreatitis			0.974
Gallstones	24 (45.3)	15 (40.5)
Alcohol	10 (18.9)	8 (21.6)
Hypertriglyceridemia	8 (15.1)	6 (16.2)
Others	11 (20.8)	8 (21.6)
Coexisting condition
Cardiovascular disease	2 (3.8)	2 (5.4)	0.999
Pulmonary disease	11 (20.8)	6 (16.2)	0.789
Renal disease	6 (11.3)	3 (8.1)	0.732
Diabetes	7 (13.2)	4 (10.8)	0.999
ASA class on admission			0.939
II	8 (15.1)	5 (13.5)
III	35 (66.0)	24 (64.9)
IV	10 (18.9)	8 (21.6)
APACHE II	8 (7-15)	7 (5-14)	0.221
APACHE II ≥20	3 (5.6)	3 (8.1)	0.687
SOFA score	0 (0-4)	0 (0-3)	0.472
CT severity index	7.2±1.6	6.8±1.7	0.303
CRP, mg/dL	141.0 (81.4-268.4)	134.3 (78.9-243.8)	0.498
WBC, ×10⁹/L	9.7 (8.1-12.7)	9.5 (7.3-11.9)	0.307
PCT, ng/mL	0.37 (0.17-0.78)	0.35 (0.18-0.69)	0.248
Preoperative SIRS	14 (26.4)	8 (21.6)	0.786
Preoperative MOF	10 (18.9)	6 (16.2)	0.965
The extent of pancreatic necrosis			0.755
<30%	6 (11.3)	4 (10.8)
30%-50%	32 (60.4)	25 (67.6)
>50%	15 (28.3)	8 (21.6)
Spread of abscess			0.037
Single abscess	38 (71.7)	34 (91.9)
Two or more abscess	15 (28.3)	3 (8.1)
Contents of collection			0.697
Homogeneous	22 (41.5)	13 (35.1)
Heterogeneous	31 (58.5)	24 (64.9)
Dimensional characterization of pancreatic necrosis, cm
Longest diameter	8.9±6.4	8.4±5.7	0.546
Shortest diameter	5.4±4.7	5.1±4.1	0.847
Gram-negative bacteria	29 (54.7)	19 (51.4)	0.920
Escherichia coli	13 (24.5)	10 (27.0)	0.983
Pseudomonas aeruginosa	7 (13.2)	3 (8.1)	0.516
Acinetobacter baumannii	4 (7.5)	2 (5.4)	0.999
Other	5 (9.4)	4 (10.8)	0.999
Gram-positive bacteria	18 (34.0)	15 (40.5)	0.678
Staphylococcus aureus	6 (11.3)	5 (13.5)	0.755
Enterococcus	8 (15.1)	7 (18.9)	0.848
Other	4 (7.5)	3 (8.1)	0.990
Fungus	6 (11.3)	3 (8.1)	0.732
One-step LPN approach
Omental sac	27 (50.9)	-
Mesenteric root	8 (15.1)	-
Paracolic sulic	4 (7.5)	-
Combination of multiple approaches	14 (26.4)	-
Surgical step-up approach*
Trans-lesser sac	-	15 (53.6)
Retroperitoneal	-	7 (25.0)
Combination of multiple approaches	-	6 (21.4)
Time to surgery from the onset of pancreatitis, d	24 (10-34)	32 (21-43)	<0.001
Time to surgery from hospitalization, d	13 (6-19)	21 (11-31)	<0.001
ICU stay of preoperative, d	5 (0-10)	6 (0-12)	0.561
Convert to laparotomy	3 (5.7)	3 (8.1)	0.687
Tertiary referral	30 (56.6)	23 (62.2)	0.757

Table 1.

Table 2.

Table 3.

Table 4.

References 31

1	Xiao AY, Tan MLY, Wu LM, Asrani VM, Windsor JA, Yadav D, et al. Global incidence and mortality of pancreatic diseases: a systematic review, meta-analysis, and meta-regression of population-based cohort studies. Lancet Gastroenterol Hepatol. 2016; 1(1): 45-55.
2	Boxhoorn L, Voermans RP, Bouwense SA, Bruno MJ, Verdonk RC, Boermeester MA, et al. Acute pancreatitis. Lancet. 2020; 396(10252): 726-34. doi: S0140-6736(20)31310-6 pmid: 32891214
3	Bugiantella W, Rondelli F, Boni M, Stella P, Polistena A, Sanguinetti A, et al. Necrotizing pancreatitis: a review of the interventions. Int J Surg. 2016; 28(Suppl 1): S163-71. doi: 10.1016/j.ijsu.2015.12.038
4	Gurusamy KS, Belgaumkar AP, Haswell A, Pereira SP, Davidson BR. Interventions for necrotising pancreatitis. Cochrane Database Syst Rev. 2016; 4: CD011383.
5	Raraty MGT, Halloran CM, Dodd S, Ghaneh P, Connor S, Evans J, et al. Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg. 2010; 251(5): 787-93. doi: 10.1097/SLA.0b013e3181d96c53
6	van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010; 362(16): 1491-502. doi: 10.1056/NEJMoa0908821
7	Tu YL, Jiao HB, Tan XL, Sun LY, Zhang WZ. Laparotomy versus retroperitoneal laparoscopy in debridement and drainage of retroperitoneal infected necrosis in severe acute pancreatitis. Surg Endosc. 2013; 27(11): 4217-23. doi: 10.1007/s00464-013-3026-0
8	Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013; 62(1):102-11. doi: 10.1136/gutjnl-2012-302779
9	Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association clinical practice update: management of pancreatic necrosis. Gastroenterology. 2020; 158(1): 67-75.e1. doi: S0016-5085(19)41293-6 pmid: 31479658
10	Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017; 152(3):292-8. doi: 10.1001/jamasurg.2016.4952 pmid: 28097305
11	Li A, Cao F, Li J, Fang Y, Wang XH, Liu DG, et al. Step-up mini-invasive surgery for infected pancreatic necrosis: results from prospective cohort study. Pancreatology. 2016; 16(4): 508-14. doi: 10.1016/j.pan.2016.03.014
12	Hollemans RA, Bakker OJ, Boermeester MA, Bollen TL, Bosscha K, Bruno MJ, et al. Superiority of step-up approach vs open necrosectomy in long-term follow-up of patients with necrotizing pancreatitis. Gastroenterology. 2019; 156(4): 1016-26. doi: S0016-5085(18)35202-8 pmid: 30391468
13	van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet. 2018; 391(10115): 51-8. doi: S0140-6736(17)32404-2 pmid: 29108721
14	Liu ZW, Yang SZ, Wang PF, Feng J, He L, Du JD, et al. Minimal-access retroperitoneal pancreatic necrosectomy for infected necrotizing pancreatitis: a multicentre study of a step-up approach. Br J Surg. 2020; 107(10): 1344-53. doi: 10.1002/bjs.11619
15	Zerem E, Imamović G, Sušić A, Haračić B. Step-up approach to infected necrotising pancreatitis: a 20-year experience of percutaneous drainage in a single centre. Dig Liver Dis. 2011; 43(6): 478-83. doi: 10.1016/j.dld.2011.02.020
16	De Waele JJ. A step-up approach, or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010; 363(13):1286. doi: 10.1056/NEJMc1005950
17	van Brunschot S, Hollemans RA, Bakker OJ, Besselink MG, Baron TH, Beger HG, et al. Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients. Gut. 2018; 67(4): 697-706. doi: 10.1136/gutjnl-2016-313341 pmid: 28774886
18	Hines OJ, Pandol SJ. Management of severe acute pancreatitis. BMJ. 2019; 367: l6227.
19	Cao F, Duan N, Gao CC, Li A, Li F. One-step verse step-up laparoscopic-assisted necrosectomy for infected pancreatic necrosis. Dig Surg. 2020; 37(3): 211-9. doi: 10.1159/000501076
20	Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, et al. An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis. Gastroenterology. 2019; 156(4): 1027-40.e3. doi: 10.1053/j.gastro.2018.11.031
21	Bang JY, Wilcox CM, Arnoletti JP, Varadarajulu S. Superiority of endoscopic interventions over minimally invasive surgery for infected necrotizing pancreatitis: meta-analysis of randomized trials. Dig Endosc. 2020; 32(3): 298-308. doi: 10.1111/den.13470
22	Garg PK, Zyromski NJ, Freeman ML. Infected necrotizing pancreatitis: evolving interventional strategies from minimally invasive surgery to endoscopic therapy-evidence mounts, but one size does not fit all. Gastroenterology. 2019; 156(4): 867-71. doi: 10.1053/j.gastro.2019.02.015
23	Yasuda I, Nakashima M, Iwai T, Isayama H, Itoi T, Hisai H, et al. Japanese multicenter experience of endoscopic necrosectomy for infected walled-off pancreatic necrosis: the JENIPaN study. Endoscopy. 2013; 45(8): 627-34. doi: 10.1055/s-0033-1344027 pmid: 23807806
24	Mathew A, Biswas A, Meitz KP. Endoscopic necrosectomy as primary treatment for infected peripancreatic fluid collections (with video). Gastrointest Endosc. 2008; 68(4): 776-82. doi: 10.1016/j.gie.2008.05.010
25	Dhingra R, Srivastava S, Behra S, Vadiraj PK, Venuthurimilli A, Shalimar, et al. Single or multiport percutaneous endoscopic necrosectomy performed with the patient under conscious sedation is a safe and effective treatment for infected pancreatic necrosis (with video). Gastrointest Endosc. 2015; 81(2): 351-9. doi: 10.1016/j.gie.2014.07.060 pmid: 25293824
26	Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL, et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012; 307(10): 1053-61. doi: 10.1001/jama.2012.276 pmid: 22416101
27	Worhunsky DJ, Qadan M, Dua MM, Park WG, Poultsides GA, Norton JA, et al. Laparoscopic transgastric necrosectomy for the management of pancreatic necrosis. J Am Coll Surg. 2014; 219(4): 735-43. doi: 10.1016/j.jamcollsurg.2014.04.012
28	Hollemans RA, Bollen TL, van Brunschot S, Bakker OJ, Ali UA, van Goor H, et al. Predicting success of catheter drainage in infected necrotizing pancreatitis. Ann Surg. 2016; 263(4): 787-92. doi: 10.1097/SLA.0000000000001203 pmid: 25775071
29	Mathew MJ, Parmar AK, Sahu D, Reddy PK. Laparoscopic necrosectomy in acute necrotizing pancreatitis: our experience. J Minim Access Surg. 2014; 10(3): 126-31. doi: 10.4103/0972-9941.134875 pmid: 25013328
30	Horvath KD, Kao LS, Ali A, Wherry KL, Pellegrini CA, Sinanan MN. Laparoscopic assisted percutaneous drainage of infected pancreatic necrosis. Surg Endosc. 2001; 15(7): 677-82. pmid: 11591967
31	Adamson GD, Cuschieri A. Multimedia article. Laparoscopic infracolic necrosectomy for infected pancreatic necrosis. Surg Endosc. 2003; 17(10): 1675. pmid: 14973724

Variables	One-step LPN group (n = 53)	Surgical step-up group (n = 37)	P-value
Major complications or death	9 (17.0)	8 (21.6)	0.780
Major complication	8 (15.1)	7 (18.9)	0.848
New-onset MOF	4 (7.5)	4 (10.8)	0.712
Intraabdominal bleeding	3 (5.6)	4 (10.8)	0.440
Enterocutaneous fistula	0	0
Perforation of a visceral organ	0	0
New-onset infection	4 (7.5)	2 (5.4)	0.999
Death	3 (5.6)	2 (5.4)	0.999
Pancreatic fistula	7 (13.2)	6 (16.2)	0.924
Additional pancreatic necrosectomy	3 (5.6)	4 (10.8)	0.440
New-onset SIRS	6 (11.3)	6 (16.2)	0.541
New-onset admitted to ICU	3 (5.6)	3 (8.1)	0.687
New-onset diabetes	5 (9.4)	4 (10.8)	0.999
New-onset pancreatic exocrine insufficiency	4 (7.5)	4 (10.8)	0.712
CRP, mg/dL	43.2 (25.1-71.5)	43.7 (27.8-73.5)	0.514
WBC, ×10⁹/L	5.9 (5.2-12.9)	6.4 (5.3-13.1)	0.201
PCT, ng/mL	0.19 (0.14-0.25)	0.20 (0.14-0.28)	0.364
Operation time, min	121.7±47.6	109.3±38.4	0.329
Total length of ICU stay, d	7 (0-25)	9 (0-28)	0.552
Postoperative ICU stay, d	1 (0-10)	2 (0-11)	0.565
Length of hospital stay, d	24 (17-35)	31 (21-45)	<0.001

Variables	OR (95% CI)	P-value
Gender	1.328 (0.466-3.951)	0.599
Age	0.964 (0.918-1.008)	0.119
CT severity index	1.474 (1.099-2.027)	0.012
CRP	1.010 (1.001-1.020)	0.032
WBC	1.195 (1.052-1.391)	0.011
PCT	1.452 (0.943-3.399)	0.203
ASA class IV	4.922 (1.386-20.457)	0.018
APACHE II	1.230 (1.101-1.415)	0.001
Preoperative SIRS	2.619 (0.892-7.958)	0.082
Preoperative MOF	5.647 (1.437-28.335)	0.019
Surgical approach (One-step/Step-up)	1.328 (0.466-3.951)	0.600
Time to surgery	1.008 (0.989-1.028)	0.428

Variables	OR (95% CI)	P-value
CT severity index	1.432 (1.040-2.019)	0.032
ASA class IV	5.265 (1.275-25.517)	0.027
WBC	1.171 (1.014-1.376)	0.040