Open Surgical versus Minimal Invasive Necrosectomy of the Pancreas-A Retrospective Multicenter Analysis of the German Pancreatitis Study Group.
BACKGROUND
Necrotising pancreatitis, and particularly infected necrosis, are still associated with high morbidity and mortality. Since 2011, a step-up approach with lower morbidity rates compared to initial open necrosectomy has been established. However, mortality and complication rates of this complex treatment are hardly studied thereafter.


METHODS
The German Pancreatitis Study Group performed a multicenter, retrospective study including 220 patients with necrotising pancreatitis requiring intervention, treated at 10 hospitals in Germany between January 2008 and June 2014. Data were analysed for the primary endpoints "severe complications" and "mortality" as well as secondary endpoints including "length of hospital stay", "follow up", and predisposing or prognostic factors.


RESULTS
Of all patients 13.6% were treated primarily with surgery and 86.4% underwent a step-up approach. More men (71.8%) required intervention for necrotising pancreatitis. The most frequent etiology was biliary (41.4%) followed by alcohol (29.1%). Compared to open necrosectomy, the step-up approach was associated with a lower number of severe complications (primary composite endpoint including sepsis, persistent multiorgan dysfunction syndrome (MODS) and erosion bleeding: 44.7% vs. 73.3%), lower mortality (10.5% vs. 33.3%) and lower rates of diabetes mellitus type 3c (4.7% vs. 33.3%). Low hematocrit and low blood urea nitrogen at admission as well as a history of acute pancreatitis were prognostic for less complications in necrotising pancreatitis. A combination of drainage with endoscopic necrosectomy resulted in the lowest rate of severe complications.


CONCLUSIONS
A step-up approach starting with minimal invasive drainage techniques and endoscopic necrosectomy results in a significant reduction of morbidity and mortality in necrotising pancreatitis compared to a primarily surgical intervention.
II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
Sebastian
S
Rasch
II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
Veit
V
Phillip
Department for Gastroenterology, SRH Wald-Klinikum Gera, Gera, Germany.
Stephanie
S
Reichel
Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany.
Bettina
B
Rau
Division of Gastroenterology and Rheumatology, Department of Internal Medicine, Neurology and Dermatology, University of Leipzig, Leipzig, Germany.
Christian
C
Zapf
Division of Gastroenterology and Rheumatology, Department of Internal Medicine, Neurology and Dermatology, University of Leipzig, Leipzig, Germany.
Jonas
J
Rosendahl
Department of Internal Medicine II, HELIOS Park-Klinikum, Leipzig, Germany.
Ulrich
U
Halm
Department of Internal Medicine II, HELIOS Park-Klinikum, Leipzig, Germany.
Markus
M
Zachäus
Department of Internal Medicine I, Ulm University, Ulm, Germany.
Martin
M
Müller
Department of Internal Medicine I, Ulm University, Ulm, Germany.
Alexander
A
Kleger
Department of Gastroenterology, Endocrinology, Infectiology and Metabolism, Philipps-University, Marburg, Germany.|Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Goettingen, Germany.
Albrecht
A
Neesse
Department of Internal Medicine I, University Hospital Dresden, Dresden University of Technology, Dresden, Germany.|Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany.
Jochen
J
Hampe
Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany.
Mark
M
Ellrichmann
Department of Surgery, University Hospital Mannheim, University of Heidelberg, Heidelberg, Germany.
Felix
F
Rückert
Department of General and Vascular Surgery, Ostalb-Klinikum Aalen, Aalen, Germany.
Peter
P
Strauß
Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany.
Alexander
A
Arlt
Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Goettingen, Germany.
Volker
V
Ellenrieder
Department of Gastroenterology, Endocrinology, Infectiology and Metabolism, Philipps-University, Marburg, Germany.
Thomas M
TM
Gress
Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, München, Germany.
Werner
W
Hartwig
Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Rostock, Germany.
Ernst
E
Klar
Division of Gastroenterology and Rheumatology, Department of Internal Medicine, Neurology and Dermatology, University of Leipzig, Leipzig, Germany.
Joachim
J
Mössner
Department of Surgery, University Hospital Mannheim, University of Heidelberg, Heidelberg, Germany.
Stefan
S
Post
II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
Roland M
RM
Schmid
Department of Internal Medicine I, Ulm University, Ulm, Germany.
Thomas
T
Seufferlein
Department of General and Vascular Surgery, Ostalb-Klinikum Aalen, Aalen, Germany.
Marco
M
Siech
Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Hospital of the University of Munich, München, Germany.
Jens
J
Werner
Department for Gastroenterology, SRH Wald-Klinikum Gera, Gera, Germany.
Uwe
U
Will
II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Germany.
Hana
H
Algül
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