“The ability to predict those patients with necrotizing pancreatitis (NP) likely to succeed with percutaneous drainage (PD) alone (and conversely those patients likely to require an escalation to more invasive necrosis intervention) can significantly streamline clinical decision making,” explains Thomas Maatman, MD. “Those patients predicted to achieve disease resolution with PD alone might undergo planned drain repositioning, drain upsizing, and/or additional drain placement over the subsequent days to weeks with expected success. Alternatively, when predictors of failure are present, early escalation to more definitive necrosis intervention may prevent ongoing physiologic atrophy associated with prolonged percutaneous intervention, allowing for efficient progression through the treatment algorithm and improved outcomes.”
For a study published in Pancreatology, Dr. Maatman and colleagues sought to determine if specific locations or patterns of necrosis (ie, necrosis morphology) are more amenable to PD as a definitive necrosis treatment strategy, as well as if disconnected pancreatic duct syndrome (DPDS) impacts the ability to achieve definitive necrosis resolution with PD alone. Outcomes of patients with NP treated between 2005 and 2018 were compared based on whether they achieved disease resolution with PD alone or required escalation in intervention.
While no difference was observed in necrosis morphology between the two groups and both had similar mortality rates and months to NP resolution, the PD group underwent significantly more repeat percutaneous interventions, and those with DPDS were more likely to require escalation in intervention. “Individual patient necrosis morphology alone does not predict success (or failure) of PD in NP requiring intervention,” adds Dr. Maatman. “PD is an important minimally invasive necrosis intervention that achieved definitive disease resolution in one-third of patients and acted as a bridge to other modalities of debridement in the remaining patients. While the presence of DPDS was associated with a 3.4-fold increased likelihood of failed definitive necrosis management with PD alone, one-fourth of patients with DPDS treated by PD achieved definitive necrosis resolution without the need for an escalation in intervention. Thus, the presence of DPDS does not preclude the placement of a percutaneous drain as the initial intervention in necrotizing pancreatitis.”
Dr. Maatman adds that the study highlights the need to tailor necrotizing pancreatitis interventions to the individual patient and under the guidance of an experienced multidisciplinary team using available institutional expertise.
Rebecca Shover