Transmural Versus Percutaneous Endoscopic Necrosectomy For Acute Necrotizing Pancreatitis

Background and purpose:Current studies have shown that the prognosis of endoscopic transmural necrosectomy(TEN)in the treatment of acute necrotizing pancreatitis(ANP)is better than percutaneous endoscopic necrosectomy(PEN).However,the clinical efficacy and safety of the two have not been reported.We aimed to compare clinical outcomes between TEN and PEN for acute necrotizing pancreatitis(ANP),and identify risk factors for complications after endoscopic necrosectomy and mortality.Methods:A retrospective analysis of patients with ANP who hospitalized at the pancreatic center of the First Affiliated Hospital of Nanchang University from January 2014 to December 2020.Among patients with ANP,280 patients received one of two minimally invasive therapies.Exclude patients who underwent open surgery before endoscopic necrosectomy,patients who underwent TEN+PTN combination therapy.According to the minimally invasive step-up therapy,patients were divided into two groups.TEN group:transgastric puncture and drainage under the guidance of endoscopy(EUS),followed by transgastric transmural debridement under endoscopy;PEN group: percutaneous Endoscopic sinus debridement of necrotic tissue,that is,first percutaneous puncture and drainage,and then percutaneous sinus debridement.1.The Chi-square test statistical method were used to compare the prognosis of the two groups in terms of mortality,major complications,etc.;use the two-tailed Mann-Whitney U test statistical method to compare the two groups in terms of the age,BMI,CRP,PCT,APACHE II score,CTSI score,SIRS score and other baseline data.2.Use Logistic regression analysis to determine the risk factors of complications after endoscopic debridement.3.Logistic Regression analysis was used to determine the risk factors of mortality.Results:According to the inclusion and exclusion criteria,280 ANP patients were finally included,including 138 in the TEN group and 142 in the PEN group.1.The overall average age of the included patients was 47.6(39-55)years old,including 161 males(57.5%)and 119 females(42.5%).There were no significant differences in baseline characteristics between the two groups,including gender,age,AP etiology,smoking history,and drinking history(P>0.05).However,the BMI value of the PEN group [25.0 kg/㎡(22.1 kg/㎡,27.1 kg/㎡)VS 23.9 kg/㎡(21.0 kg/㎡,26.6 kg/㎡)],CRP within 24 hours of admission [188.7mg/dl(86.4mg/dl,270.0mg/dl)VS 142.3mg/dl(26.2mg/dl,230.0mg/dl)],PCT [8.3ng/L(0.4ng/L,7.9ng/L)VS3.8ng/L(0.25ng/L,3.2ng/L)],APACHE II score [9.2(5.3,12.0)VS 7.9(4.0,11.0)],SIRS score [2.1(1.0,3.0)VS 1.5(0,2.0)],Respiratory failure before initial drainage(27.5% vs 40.8%),renal failure(6.5% vs 14.1%),sepsis before initial debridement(26.8% VS 15.2%),and respiratory failure before debridement(45.8% VS 31.2%).It was higher than the TEN group(all P values <0.05).2、According to analysis,it was found that the mortality rate of patients in the TEN group and the PEN group was equivalent(20.3% VS 19.7%,P=0.905).New complications after endoscopic necrotic tissue debridement included new IPN after debridement(2.9 % VS 2.8%,P=1.000),new-onset sepsis after debridement(8.0%VS 7.7%,P=0.944),new-onset acute respiratory failure(10.1% VS 8.5%,P=0.625),new-onset renal failure(2.0% VS 0%,P=0.118),new circulatory failure(10.1% VS9.9%,P=0.936),new abdominal bleeding(5.8% VS 9.9%,P=0.207),new gastrointestinal bleeding(5.1% VS 1.4%,P=0.162),new intestinal-cutaneous fistula(5.8% VS 6.3%,P=0.850),new pancreatic-cutaneous fistula(0.7% VS 3.5%,P=0.214),etc.Significant difference;salvage treatment after debridement including DSA hemostasis(2.2% VS 3.5%,P=0.751)and open surgery(6.5% VS 8.5%,P=0.540)were also not statistically different.3、The total hospital stay of patients in the TEN group [39.6(22.0,51.3)VS57.6(39.8,72.3)],ICU stay time [10.3(0,12.5)VS 18.3(0,31.0)] and hospitalization expenses [105179.0(56008.9,190255.0)VS 185267.3(115127.3,356186.0)] were lower than the PEN group,and there was a significant statistical difference(P<0.05).4 、 A univariate Logistic regression analysis was performed on the complications after endoscopic debridement.The results suggest that the APACHEII score ≥8(OR 2.056,95% CI 1.256-3.365),CRP(OR 1.193,95% CI 0.948-1.501),Pancreatic necrosis area>50%(OR 5.119,95% CI 2.628-9.972),sepsis before debridement(OR 4.002,95% CI 2.175-7.361),IPN before drainage(OR 0.526,95%CI 0.220-6.114),clear Pre-traumatic ICU stay(OR 2.229,95% CI 1.288-3.857)had an impact on the incidence of complications after endoscopic debridement;multivariate Logistic regression analysis showed that the APACHEII score≥8 at admission(OR 0.483,95% CI 0.261-0.892;P <0.05),area of pancreatic necrosis> 50%(OR 0.221,95% CI 0.101-0.481;P <0.05)and sepsis before debridement(OR 0.321,95% CI 0.144-0.716;P <0.05)are clear Risk factors for post-traumatic complications.5、A univariate logistic regression analysis was performed on death,and the results suggested age(OR 1.833,95% CI 0.956-3.514),hyperlipidemia pancreatitis(OR 0.789,95% CI 0.412-1.512),CRP(OR 1.193,95% CI 0.948-1.501),PCT(OR1.189,95% CI 0.950-1.489),sepsis before debridement(OR 4.002,95% CI 2.175-7.361),multiple organ failure(MOF)(OR 3.221,95% CI 1.677-6.187),pre-drainage respiratory failure(OR 0.477,95% CI 0.159-1.428)all have an impact on mortality;multivariate logistic regression analysis showed that MOF before debridement(OR0.286,95% CI 0.113-0.525;P <0.05)is the independent risk factor for mortality.Conclusion:1.There is no significant difference between TEN and PEN in the treatmentrelated complications and mortality of ANP.2.Patients in the PEN group were more severely ill.Within 24 hours of admission,CRP,PCT,APACHE II score,SIRS score,respiratory failure before initial drainage,renal failure,sepsis before initial debridement,and respiratory failure before debridement were all higher than those in the TEN group.3.Patients in the TEN group had lower total hospitalization time,ICU stay time and hospitalization costs than the PEN group.4.APACHEII score ≥8 at admission,area of pancreatic necrosis before debridement >50%,and sepsis before debridement are independent risk factors for complications after debridement in patients with acute necrotizing pancreatitis.5.Multiple organ failure before debridement is an independent risk factor for death in ANP patients.