First Look: The American Surgical Association

The American Surgical Association held its 141st annual meeting virtually this year. Here, General Surgery News presents one of the most important papers from the meeting.

The complete manuscript of this study and its presentation at the ASA meeting are anticipated to be published in the Annals of Surgery pending editorial review.

Patients required fewer interventions, spent less time in the hospital and had fewer readmissions after undergoing operative rather than endoscopic transgastric debridement for necrotizing pancreatitis, according to one of the largest case series of patients treated for this condition.

But the authors say their results demonstrate that both approaches have a place in management of necrotizing pancreatitis.

Instead of advocating one approach over the other, investigators called for multidisciplinary collaboration in caring for these patients, including clinicians who have experience in surgical and endoscopic treatment, as well as percutaneous treatment and medical therapy.

“This is a team effort. It takes experienced judgment and multidisciplinary teamwork with GI and surgery to determine the optimal approach to treating necrotizing pancreatitis, whether it’s surgical or endoscopic,” said lead author Nicholas J. Zyromski, MD, a professor of surgery at Indiana University School of Medicine in Indianapolis.

Some patients treated operatively later received endoscopic and percutaneous treatment, while some treated by endoscopy required subsequent operations, he noted.

The study included 643 patients with pancreatic necrosis who were treated at Indiana University Hospital between 2008 and 2019. In this group, 160 patients underwent transgastric debridement: 59 were treated endoscopically (37%) and 101 operatively (63%).

A multidisciplinary team made the decision on whether to use endoscopy or surgery after considering the patient’s history, the disease etiology and clinical characteristics.

Patients treated endoscopically required 3.0±2.0 debridements per patient, compared with 1.1±0.5 in the surgical group. Overall, 81% of patients who had endoscopic transgastric debridement required repeat interventions, up from 7% in the surgical group.

The endoscopic approach was associated with longer postoperative lengths of stay in the hospital (13.8±20.8 vs. 9.4±6.1 days; P=0.047). Patients treated endoscopically also had higher rates of readmission (67% vs. 20%; P<0.001).

Surgical transgastric debridement should be the first choice for patients with biliary necrotizing pancreatitis and suitable anatomy, while patients with alcoholic pancreatitis or hypertriglyceridemic pancreatitis may be better suited for an endoscopic approach, Dr. Zyromski said.

More patients died in the endoscopic group (7% vs. 1%), and new-onset organ failure was similar in the two groups at 13%.

Investigators said mechanical intervention for necrotizing pancreatitis should be delayed at least four to six weeks after onset.