Improved Mortality in Necrotizing Pancreatitis with a Multidisciplinary Minimally Invasive Step Up Approach: Comparison to a Modern Open Necrosectomy Cohort.

Background A minimally invasive step-up (MIS) approach has been associated with reduced morbidity compared to open surgical necrosectomy (OSN) for treatment of necrotizing pancreatitis (NP). We sought to determine if transitioning from an OSN to an MIS-based approach would result in reduced mortality. MIS interventions included percutaneous drainage (PD), endoscopic transgastric necrosectomy (ETN), video-assisted retroperitoneal debridement (VARD), sinus tract endoscopic necrosectomy (STE), or a combination of techniques, with selective use of OSN. Study Design Observational cohort study with retrospective comparison at a single tertiary referral center (2006-2019). 88 patients were treated with OSN and 91 were treated with a MIS-based approach. Baseline characteristics and clinical outcomes were compared between groups. The primary outcome was 90-day mortality. Results There was no difference in baseline characteristics. 90-day mortality was 2% with MIS compared to 10% with OSN (p=0.03). One-year mortality was 3% with MIS compared to 15% with OSN (p=0.012). The rate of organ failure was lower with MIS (30% vs 45%, p=0.029), but there was a higher bleeding rate (19% vs 9%) (p=0.064). In the MIS group, 9% were treated with PD, 32% with ETN, 8% with VARD, 15% with STE, and 27% with a combination of techniques. Conclusion Adoption of a multidisciplinary MIS-based approach to NP resulted in a 5-fold decrease in mortality compared to OSN.