Kazuhiro Minami1, Masayasu Horibe1,2, Masamitsu Sanui3, Mitsuhito Sasaki4, Eisuke Iwasaki1, Hirotaka Sawano5, Takashi Goto6, Tsukasa Ikeura7, Tsuyoshi Takeda8, Takuya Oda9, Hideto Yasuda10, Yuki Ogura2, Dai Miyazaki11, Katsuya Kitamura12,13, Nobutaka Chiba14, Tetsu Ozaki15, Takahiro Yamashita16,17, Toshitaka Koinuma18, Taku Oshima19, Tomonori Yamamoto20, Morihisa Hirota21, Natsuko Tokuhira22, Yoshinori Azumi23, Keiji Nagata24, Kazunori Takeda25, Tomoki Furuya26, Alan Kawarai Lefor27, Toshihiko Mayumi28, Takanori Kanai1. 1. Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan. 2. Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, 2-8-29, Musashidai, Fuchu City, Tokyo, Japan. 3. Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumachou, Omiya-ku, Saitama, Saitama, 330-8503, Japan. msanui@mac.com. 4. Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan. 5. Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital, 1-1-6 Tsukumodai, Suita, Osaka, Japan. 6. Department of Anesthesiology and Intensive Care, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima City, Hiroshima, Japan. 7. Third Department of Internal Medicine, Kansai Medical University, 2-5-1, Shinmachi, Hirakata, Osaka, Japan. 8. Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan. 9. Department of General Internal Medicine, Iizuka Hospital, 3-83 Yoshiomachi, Iizuka-shi, Fukuoka, Japan. 10. Department of Emergency and Critical Care Medicine, Japanese Red Cross Musashino Hospital, 1-26-1 Kyounancho, Musashino City, Tokyo, Japan. 11. Advanced Emergency Medical and Critical Care Center, Japanese Red Cross Maebashi Hospital, 3-21-36 Asahi-cho, Maebashi City, Gunma, Japan. 12. Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, Japan. 13. Department of Gastroenterology and Hepatology, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji-shi, Tokyo, Japan. 14. Department of Emergency and Critical Care Medicine, Nihon University Hospital, 1-6 Kanda-Surugadai, Chiyoda-ku, Tokyo, Japan. 15. Department of Acute care and General Medicine, Saiseikai Kumamoto Hospital, 5-3-1 Chikami, Minami-ku, Kumamoto City, Kumamoto, Japan. 16. Emergency Medical Center, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama City, Hiroshima, Japan. 17. Acute Care Medical Center, Hyogo Prefectural Kakogawa Medical Center, 203 Kanno, Kanno-cho, Kakogawa City, Hyogo, Japan. 18. Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, Japan. 19. Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, Japan. 20. Department of Traumatology and Critical Care Medicine, Osaka City University, 1-4-3 Asahimachi, Abenoku, Osaka City, Osaka, Japan. 21. Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, 1-15-1 Fukumuro, Miyagino-ku, Sendai, Miyagi, Japan. 22. Division of Intensive Care Medicine, University Hospital, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto, Japan. 23. Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, Japan. 24. Department of Critical Care Medicine University Hospital, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahata-nishi-ku, Kitakyushu, Fukuoka, Japan. 25. Miyagi Branch Office, Health Insurance Claims Review and Reimbursement Services, 5-1-27, Tsutsujigaoka, Miyagino-ku, Sendai, Miyagi, Japan. 26. Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, Japan. 27. Department of Surgery, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke, Tochigi, Japan. 28. Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahata Nishi, Kitakyushu, Fukuoka, Japan.
Abstract
BACKGROUND: Infected acute necrotic collections (ANC) and walled-off necrosis (WON) of the pancreas are associated with high mortality. The difference in mortality between open necrosectomy and minimally invasive therapies in these patients remains unclear. METHODS: This retrospective multicenter cohort study was conducted among 44 institutions in Japan from 2009 to 2013. Patients who had undergone invasive treatment for suspected infected ANC/WON were enrolled and classified into open necrosectomy and minimally invasive treatment (laparoscopic, percutaneous, and endoscopic) groups. The association of each treatment with mortality was evaluated and compared. RESULTS: Of 1159 patients with severe acute pancreatitis, 122 with suspected infected ANC or WON underwent the following treatments: open necrosectomy (33) and minimally invasive treatment (89), (laparoscopic three, percutaneous 49, endoscopic 37). Although the open necrosectomy group had a significantly higher mortality on univariate analysis (p = 0.047), multivariate analysis showed no significant associations between open necrosectomy or Charlson index and mortality (p = 0.29, p = 0.19, respectively). However, age (for each additional 10 years, p = 0.012, odds ratio [OR] 1.50, 95% confidence interval [CI] 1.09-2.06) and revised Atlanta criteria-severe (p = 0.001, OR 7.84, 95% CI 2.40-25.6) were significantly associated with mortality. CONCLUSIONS: In patients with acute pancreatitis and infected ANC/WON, age and revised Atlanta criteria-severe classification are significantly associated with mortality whereas open necrosectomy is not. The mortality risk for patients undergoing open necrosectomy and minimally invasive treatment does not differ significantly. Although minimally invasive surgery is generally preferred for patients with infected ANC/WON, open necrosectomy may be considered if clinically indicated.
BACKGROUND: Infected acute necrotic collections (ANC) and walled-off necrosis (WON) of the pancreas are associated with high mortality. The difference in mortality between open necrosectomy and minimally invasive therapies in these patients remains unclear. METHODS: This retrospective multicenter cohort study was conducted among 44 institutions in Japan from 2009 to 2013. Patients who had undergone invasive treatment for suspected infected ANC/WON were enrolled and classified into open necrosectomy and minimally invasive treatment (laparoscopic, percutaneous, and endoscopic) groups. The association of each treatment with mortality was evaluated and compared. RESULTS: Of 1159 patients with severe acute pancreatitis, 122 with suspected infected ANC or WON underwent the following treatments: open necrosectomy (33) and minimally invasive treatment (89), (laparoscopic three, percutaneous 49, endoscopic 37). Although the open necrosectomy group had a significantly higher mortality on univariate analysis (p = 0.047), multivariate analysis showed no significant associations between open necrosectomy or Charlson index and mortality (p = 0.29, p = 0.19, respectively). However, age (for each additional 10 years, p = 0.012, odds ratio [OR] 1.50, 95% confidence interval [CI] 1.09-2.06) and revised Atlanta criteria-severe (p = 0.001, OR 7.84, 95% CI 2.40-25.6) were significantly associated with mortality. CONCLUSIONS: In patients with acute pancreatitis and infected ANC/WON, age and revised Atlanta criteria-severe classification are significantly associated with mortality whereas open necrosectomy is not. The mortality risk for patients undergoing open necrosectomy and minimally invasive treatment does not differ significantly. Although minimally invasive surgery is generally preferred for patients with infected ANC/WON, open necrosectomy may be considered if clinically indicated.
Authors: Sandra van Brunschot; Robbert A Hollemans; Olaf J Bakker; Marc G Besselink; Todd H Baron; Hans G Beger; Marja A Boermeester; Thomas L Bollen; Marco J Bruno; Ross Carter; Jeremy J French; Djalma Coelho; Björn Dahl; Marcel G Dijkgraaf; Nilesh Doctor; Peter J Fagenholz; Gyula Farkas; Carlos Fernandez Del Castillo; Paul Fockens; Martin L Freeman; Timothy B Gardner; Harry van Goor; Hein G Gooszen; Gerjon Hannink; Rajiv Lochan; Colin J McKay; John P Neoptolemos; Atilla Oláh; Rowan W Parks; Miroslav P Peev; Michael Raraty; Bettina Rau; Thomas Rösch; Maroeska Rovers; Hans Seifert; Ajith K Siriwardena; Karen D Horvath; Hjalmar C van Santvoort Journal: Gut Date: 2017-08-03 Impact factor: 23.059