title: Cyst Gastrostomy and Necrosectomy for the Management of Sterile Walled-Off Pancreatic Necrosis: a Comparison of Minimally Invasive Surgical and Endoscopic Outcomes at a High-Volume Pancreatic Center.
abstract: BACKGROUND
  Walled-off pancreatic necrosis (WON) is a sequela of acute necrotizing pancreatitis in 15-40% of cases. We sought to compare the outcomes of minimally invasive surgical and endoscopic cyst gastrostomy (CG) and necrosectomy for the management for sterile WON at a tertiary care high-volume pancreas center.
  
  
  METHODS
  This is a retrospective review of patients who underwent minimally invasive surgical or endoscopic CG and necrosectomy for clinically sterile WON between 2008 and 2013. Peri-procedural outcomes including costs were analyzed and compared.
  
  
  RESULTS
  Twenty patients underwent minimally invasive surgical (robotic = 14, laparoscopic = 6) CG and necrosectomy, and 20 patients underwent endoscopic treatment. The surgical cohort had a larger median cyst size and higher CCI score. For the surgical cohort, median OR time was 167.5 min, estimated blood loss was 30 ml, and 65% underwent concomitant cholecystectomy. There was no mortality in either group and no difference in complication rates (20%). The failure rate was similar (15 versus 10%, P = 0.66). Although surgery was associated with a lower re-intervention rate (0 versus 1, P = 0.008), the endotherapy group was associated with shorter total LOS (inclusive of re-interventions) (7 versus 3 days, P = 0.032). The cost of the index procedure was significantly higher for the surgery group (P = 0.014); however, when considering all readmissions and re-interventions until resolution of the WON, the total cost was similar for both groups.
  
  
  CONCLUSIONS
  Minimally invasive surgical and endoscopic CG and necrosectomy are comparable treatments for sterile WON in terms of outcomes and overall cost. The surgical approach may be considered advantageous when a concomitant cholecystectomy is required.
authors.affiliation: Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Khreiss
authors.forename: Mazen
authors.initials: M
authors.lastname: Zenati
authors.forename: Amber
authors.initials: A
authors.lastname: Clifford
authors.forename: Kenneth K
authors.initials: KK
authors.lastname: Lee
authors.forename: Melissa E
authors.initials: ME
authors.lastname: Hogg
authors.forename: Adam
authors.initials: A
authors.lastname: Slivka
authors.forename: Jennifer
authors.initials: J
authors.lastname: Chennat
authors.forename: Andres
authors.initials: A
authors.lastname: Gelrud
authors.forename: Herbert J
authors.initials: HJ
authors.lastname: Zeh
authors.forename: Georgios I
authors.initials: GI
authors.lastname: Papachristou
authors.forename: Amer H
authors.initials: AH
authors.lastname: Zureikat
mesh_terms: D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical; D003560:Cysts / Q000209:etiology / Q000601:surgery*; D004322:Drainage / Q000379:methods*; D016145:Endoscopy, Digestive System / Q000009:adverse effects / Q000191:economics; D005260:Female; D005774:Gastrostomy; D061847:Hospitals, High-Volume; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009336:Necrosis / Q000209:etiology / Q000601:surgery; D061646:Operative Time; D010179:Pancreas / Q000473:pathology* / Q000601:surgery*; D019283:Pancreatitis, Acute Necrotizing / Q000150:complications; D012086:Reoperation; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000191:economics; D017211:Treatment Failure