Transgastric Debridement for Necrotizing Pancreatitis Needs a Team Approach

No Difference Across Several End Points

In a presentation during the 2021 Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract 1875), Dr. Zhang noted that 606 patients preoperatively reported cannabis use, while the remaining 1,212 served as controls. The total prevalence of reported cannabis use was 4% (606/15,048).

For the propensity score–matched analyses, there was a final cohort of 524 cannabis users with complete information and 1,152 controls. No difference was found between groups with respect to the study’s primary end point: Seven cannabis users (1.2%) experienced the composite outcome of respiratory/cardiac arrest, ICU admission, stroke, myocardial infarction or mortality during their hospital stay, compared with 11 controls (0.9%), yielding an odds ratio of 1.06 (95% CI, 0.23-3.98).

Although cannabis users experienced a greater incidence of arrhythmias than controls (2.7% vs. 1.6%; P=0.15), along with a decreased incidence of postoperative nausea and vomiting requiring treatment (9.6% vs. 12.6%; P=0.08), these differences were not statistically significant. The incidence of severe pain during recovery was also comparable between groups, affecting 30.9% of cannabis users and 33.5% of their counterparts who did not use cannabis (P=0.31).

Cannabis Use Hard to Pinpoint

“More rigorous study should be designed to examine these outcomes,” Dr. Zhang said.

As the researchers discussed, the study represents the largest single-center effort examining regular cannabis use in average doses. Nevertheless, the analysis was not without its shortcomings, which included self-reporting of cannabis use (which may create underreporting); the researchers’ inability to quantify the amount, duration or type of cannabis use; and a lack of categorization of other recreational drug use.

Marco Echeverria-Villalobos, MD, an assistant professor of anesthesiology at The Ohio State University Wexner Medical Center, in Columbus, said the primary challenge in studies such as this is accurately estimating the percentage of cannabis users in a population of surgical patients.

“Despite the wide use that cannabis or cannabinoids have as recreational or medical drugs, the percentage of patients that can be identified preoperatively as recreational or medical cannabis users by self-disclosure is still very low (4.0%-4.2%), as we can observe in other studies that have included larger sample sizes [Int Orthop 2019;43:283-292]. This continues to be an important limiting factor of studies that seek to accurately estimate the real impact of cannabis use on perioperative outcomes. ■

By CHRISTINA FRANGOU

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 newonset 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. ■