Is Surgical Pancreatic Necrosectomy Becoming Obsolete? ACS-NSQIP Trends and Predictors of Complications and Mortality

Background: Surgical pancreatic necrosectomy (SPN) is an option for management of severe acute pancreatitis. Literature indicates that an escalating, combined endoscopic, interventional radiology and minimally invasive surgery “Step-up” approach such as Video-Assisted Retroperitoneal Debridement (VARD) may reduce the number of required SPNs and ICU complications such as multiple organ failure. We sought to determine temporal trends for rates of SPN, and SPN-related mortality and complications. Methods The American College of Surgeons National Surgery Quality Improvement Program database (ACS-NSQIP) was used to find SPN cases from 2007–2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses. Results There were 2457 SPN cases. SPN cases decreased from 0.09% of records in 2007 to 0.01% in 2019 (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40–27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified Frailty Index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). mFI decreased after 2010 (p < 0.001). Conclusion SPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a “Step-up” approach. Larger, prospective studies to compare indications and outcomes for SPN are warranted.