Decreasing use of pancreatic necrosectomy and NSQIP predictors of complications and mortality

Background: Surgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery "step-up" approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the "step-up" approach.

Methods: The American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses.

Results: There were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001).

Conclusion: SPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a "step-up" approach. Larger, prospective studies to compare indications and outcomes for "step up" versus open SPN are warranted.