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The Extent Of Walled-Off Necrosis In Pancreatitis Is Reproducible And Impacts Multidisciplinary Decision Making
*Mir Shanaz Hossain, *Sayf A. Said, *Breanna Perlmutter, *Alexander DeMare, *John McMichael, Daniel Joyce, Robert Simon, *Toms Augustin, R Matthew Walsh
Cleveland Clinic Foundation, Cleveland, OH

OBJECTIVE(S):
The management of necrotizing pancreatitis should involve a multimodal approach that escalates from minimally invasive procedures to major surgical intervention. Predicting the best treatment strategy to minimize morbidity and mortality while optimizing resource utilization remains difficult. Tailoring initial interventions according to reproducible assessment of disease extent may improve management strategies.
METHODS:
A retrospective review was conducted for patients who underwent intervention for necrotizing pancreatitis at a tertiary center between 2010-2018. Patients with an accessible pancreas-protocol CT within 2 weeks of the index intervention were included. Imaging was evaluated by two hepato-pancreato-biliary surgeons to classify patients according to the extent of peri-pancreatic necrotic collections - (1) confined to the retrogastric space or (2) extending beyond the retrogastric space. Two surgical trainees also evaluated the images to allow for inter-rater reliability assessment of the proposed categorization schema using the Fleiss kappa method. Demographics, interventions, and outcome variables were compared between these two patient groups. Univariate parametric and non-parametric tests were used as appropriate.
RESULTS: 85 patients were included -34(40%) had necrosis confined to the retrogastric space while 51(60%) had necrosis extend beyond the retrogastric space. Inter-rater reliability of the grading showed a substantial agreement between raters, Kappa=0.804 (95%CI 0.591-1.0, p<0.001). There was no significant difference in demographics or disease severity between the two groups. The initial intervention was similar between retrogastric vs beyond retrogastric: endoscopic 13(38%) vs 10(11%), percutaneous drainage 13(38%) vs 30(59%), or surgery 8(23%) vs 11(22%), p=0.113. Patients with confined retrogastric necrosis had significantly lower number of interventions (median of 3 interventions [IQR 1-5] vs. 4[3-8], P=0.041). The initial length of stay (LOS), cumulative LOS with subsequent readmissions, and cumulative ICU days were also significantly less for those with confined retrogastric necrosis (11.5 days[5.25-19] vs. 19[10.5-33], P=0.009; 26.5 days[14-41.5] vs. 44[27-69.5], P=0.004; and 2 days[0-10.75] vs. 13[1.5-35.5], P=0.013, respectively).
CONCLUSIONS:
Necrotizing pancreatitis presents along a continuum with regards to disease characteristics. We demonstrate that the extent of necrotic collection impacts the course of treatment, with confined retrogastric collections having more favorable outcomes. Optimizing intervention selection according to a reproducible assessment of disease extent is feasible.


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