The cost of endoscopic treatment for walled-off pancreatic necrosis.

BACKGROUND: Use of minimally invasive techniques has reduced mortality in walled-off pancreatic necrosis (WON) but may be costly. The aim of this study was to evaluate the actual costs associated with the endoscopic management of patients with WON. METHODS: We included a retrospective cohort of WON patients treated with endoscopic, transgastric drainage and necrosectomy (ETDN) during 2013-2014. Costs were calculated for six sub-areas based on a micro-costing model. Students T-test and non-parametric analysis of variance were performed to evaluate costs in relation to disease etiology and outcome. RESULTS: We included 58 patients (50% men, median age 57 years). The most common etiologies were gallstones (57%) and alcohol (19%). Nine patients (16%) died during admission. The median length of stay was 50 days (IQR 31 days). Eighteen patients (31%) needed treatment in our intensive care unit with a median length of stay of 16 days (IQR 31 days). The mean costs and standard deviation of costs (SD) per patient were: diagnostic imaging $2,431 ($2,301), laboratory tests $3,579 ($2,477), blood products $982 ($1,734), endoscopic treatment $3,794 ($1,777), medicine $5,440 ($6,656), and ward cost $41,260 ($35,854). The mean total cost was $57,486 ($46,739). Post-ERCP pancreatitis and mortality predicted higher costs. CONCLUSIONS: This study sheds light on the different costs associated with endoscopic treatment of WON. As nearly three quarters of the costs are related to ward care, initiatives aimed at reducing the length of hospital stay may have a great impact on making endoscopic treatment more cost effective.

Outcomes from different minimally invasive approaches for infected necrotizing pancreatitis.

Infected necrotizing pancreatitis (INP), the leading cause of mortality in the late phase of acute pancreatitis, nearly always requires intervention. In recent years minimal invasive surgery is becoming more and more popular for the management of INP, but few studies compared different minimally invasive strategies. The objective of this observation study was to evaluate the safety and effectiveness with several minimal invasive treatment.We retrospectively reviewed cases of percutaneous catheter drainage (PCD), minimal access retroperitoneal pancreatic necrosectomy (MARPN), small incision pancreatic necrosectom (SIPN), single-incision access port retroperitoneoscopic debridement (SIAPRD) for INP between January 2013 and October 2018. Data were analyzed for the primary endpoints as well as secondary endpoints.Eighty-one patients with INP were treated by minimally invasive procedures including PCD (n = 32), MARPN (n = 18), SIPN (n = 16), and SIAPRD (n = 15). Overall mortality was greatest after PCD 34% (MARPN 11% vs SIPN 6% vs SIRLD6%). Problems after initial surgery were ongoing sepsis (PCD 56% vs MARPN 50% vs SIPN 31% vs SIAPRD13%; P < .05). There was a significant difference in number of interventions (median, 6 vs 5 vs 3 vs 2; P < .05). Time from onset of symptoms to recovery was less for SIAPRD than for PCD, MARPN, or SIPN (median, 45 vs 102 vs 80 vs 67 days; P < .05).SIAPRD remedy evidently improved outcomes, including systemic inflammatory response syndrome, number of interventions, length of hospital stay and overall cost. It is technically feasible, safe, and effective for INP, in contrast to others, and can achieve the best clinical results with the least cost. Furthermore, relevant multicentre randomized controlled trials are eager to prove these findings.

Superiority of Step-up Approach vs Open Necrosectomy in Long-term Follow-up of Patients With Necrotizing Pancreatitis.

BACKGROUND & AIMS: In a 2010 randomized trial (the PANTER trial), a surgical step-up approach for infected necrotizing pancreatitis was found to reduce the composite endpoint of death or major complications compared with open necrosectomy; 35% of patients were successfully treated with simple catheter drainage only. There is concern, however, that minimally invasive treatment increases the need for reinterventions for residual peripancreatic necrotic collections and other complications during the long term. We therefore performed a long-term follow-up study. METHODS: We reevaluated all the 73 patients (of the 88 patients randomly assigned to groups) who were still alive after the index admission, at a mean 86 months (±11 months) of follow-up. We collected data on all clinical and health care resource utilization endpoints through this follow-up period. The primary endpoint was death or major complications (the same as for the PANTER trial). We also measured exocrine insufficiency, quality of life (using the Short Form-36 and EuroQol 5 dimensions forms), and Izbicki pain scores. RESULTS: From index admission to long-term follow-up, 19 patients (44%) died or had major complications in the step-up group compared with 33 patients (73%) in the open-necrosectomy group (P = .005). Significantly lower proportions of patients in the step-up group had incisional hernias (23% vs 53%; P = .004), pancreatic exocrine insufficiency (29% vs 56%; P = .03), or endocrine insufficiency (40% vs 64%; P = .05). There were no significant differences between groups in proportions of patients requiring additional drainage procedures (11% vs 13%; P = .99) or pancreatic surgery (11% vs 5%; P = .43), or in recurrent acute pancreatitis, chronic pancreatitis, Izbicki pain scores, or medical costs. Quality of life increased during follow-up without a significant difference between groups. CONCLUSIONS: In an analysis of long-term outcomes of trial participants, we found the step-up approach for necrotizing pancreatitis to be superior to open necrosectomy, without increased risk of reinterventions.

Endoscopic ultrasound-guided placement of plastic vs. biflanged metal stents for therapy of walled-off necrosis: a retrospective single-center series.

BACKGROUND AND STUDY AIMS: Recently, a novel fully covered and biflanged metal stent (BFMS)dedicated to the drainage of walled-off necrosis(WON) was developed. The aim of this study was to retrospectively evaluate the safety, efficacy, and cost performance of drainage of WON using the novel BFMS compared with a traditional plastic stent. PATIENTS AND METHODS: A total of 70 patients with symptomatic WON were treated under endoscopic ultrasound (EUS) guidance. Initial drainage was conducted using the single gateway technique with placement of one or more plastic stents or a single BFMS.If drainage was unsuccessful,direct endoscopic necrosectomy (DEN)was performed. RESULTS: There were no statistically significant differences in rates of technical success, clinical success,and adverse events between plastics stents and BFMS, despite the size of WON in the BFMS group being significantly larger than that in the plastic stent group (105.6 vs. 77.1 mm; P=0.003).The mean procedure times for the first EUS-guided drainage and for re-intervention were significantly shorter in the BFMS group than in the plastic stent group (28.8±7.1 vs. 42.6±14.2, respectively,for drainage, P<0.001; and 34.9±8.5 vs.41.8±7.6, respectively, for re-intervention, P<0.001). There was no statistically significant difference in the total cost between plastic stent and BFMS use in the treatment of WON ($5352vs. $6274; P=0.25). CONCLUSIONS: Plastic stents and BFMS were safe and effective for the treatment of WON. In particular,BFMS placement appeared to be preferable for initial EUS-guided drainage and additional reintervention(e.g. DEN) as it reduced the procedure time. Prospective randomized controlled trials are warranted.

Direct endoscopic necrosectomy versus step-up approach for walled-off pancreatic necrosis: comparison of clinical outcome and health care utilization.

OBJECTIVES: Infected walled-off pancreatic necrosis (WOPN) is a complication of acute pancreatitis requiring intervention. Surgery is associated with considerable morbidity. Percutaneous catheter drainage (PCD), initial therapy in the step-up approach, minimizes complications. Direct endoscopic necrosectomy (DEN) has demonstrated safety and efficacy. We compared outcome and health care utilization of DEN versus step-up approach. METHODS: This was a matched cohort study using a prospective registry. Twelve consecutive DEN patients were matched with 12 step-up approach patients. Outcomes were clinical resolution after primary therapeutic modality, new organ failure, mortality, endocrine or exocrine insufficiency, length of stay, and health care utilization. RESULTS: Clinical resolution in 11 of 12 patients after DEN versus 3 of 12 step-up approach patients after PCD (P < 0.01). Nine step-up approach patients required surgery; 7 of these experienced complications. Direct endoscopic necrosectomy resulted in less new antibiotic use, pulmonary failure, endocrine insufficiency, and shorter length of stay (P < 0.05). Health care utilization was lower after DEN by 5.2:1 (P < 0.01). CONCLUSIONS: Direct endoscopic necrosectomy may be superior to step-up approach for WOPN with suspected or established infection. Primary PCD generally delayed definitive therapy. Given the higher efficacy, shorter length of stay, and lower health care utilization, DEN could be the first-line therapy for WOPN, with primary PCD for inaccessible or immature collections.

[The clinical analysis of a step-up approach for severe acute pancreatitis: report of 121 cases].

OBJECTIVE: To investigate the feasibility and clinical value of the step-up approach for severe acute pancreatitis (SAP). METHODS: Clinical data of 121 SAP patients admitted between January 2002 and December 2011 were retrospectively analyzed. Fifty-eight patients (37 males and 21 females, aged from 20 to 72 years, mean 47.6 years) in the group of direct open necrosectomy from January 2002 to December 2006 were performed laparotomy through removal of all necrotic tissue. Sixty-three patients (42 males and 21 females, aged from 19 to 78 years, mean 46.2 years) of step-up approach from January 2007 to December 2011 underwent percutaneous catheter drainage through retroperitoneum or omental bursa guided by B-type ultrasonography for the first therapy, and then, according to the pathogenetic condition, if necessary, followed by a small incisional necrosectomy along the drainage tube. The two groups were compared for the rates of postoperative complications, death, transfusion and length of stay, medical costs. RESULTS: The rates of total postoperative complications, organ dysfunction, alimentary tract fistula and incisional hernia in step-up approach group were significantly lower than those of direct open necrosectomy group (31.7% vs. 62.1%, 14.3% vs. 37.5%, 6.3% vs. 19.0%, 9.5% vs. 29.3%; χ(2) = 4.43 to 11.17, P = 0.001 to 0.035). The other complications had no significant differences between the two groups (P > 0.05). Patients in step-up approach group had a lower rates of transfusion (44.4% vs. 70.7%, χ(2) = 8.488, P = 0.004), fewer medical costs of transfusion and hospital stay, compared with those in direct open necrosectomy group ((2525 ± 4573) yuan vs. (4770 ± 6867) yuan, t = 2.131, P = 0.035; (171 213 ± 50 917) yuan vs. (237 874 ± 67 832) yuan, t = 2.496, P = 0.014). There were no significant differences of length of stay and mortality between two groups (P > 0.05). CONCLUSION: Step-up approach for SAP which can reduce the rates of postoperative complications, transfusion and medical costs has significant feasibility and great clinical value.

Severe necrotic and septic pancreatitis. Indications to endoscopic, surgical, and nutritional therapy.

Severe acute pancreatitis (SAP) management has changed over the last fifteen years, and from too aggressive behaviour, we moved to a cautious one. In every case, we can appreciate defect of extremist conceptual position. We reviewed our strategy on disease treatment, and we analyzed treatment of single cases. We collected 4 SAP cases from January 2009 to January 2010. All patients were septic, and we adopted the same approach for all of them, avoiding surgery without peritoneal infection. In all patients we placed jejumostomy and, after cleaning of septic site, we started immediate enteral nutrition (EN). Antibiotic therapy against Gram+, Gram- and antifugal drug had been started. No one died and all patients were back to an active life even if social costs are considerably high especially due to very long hospital stay.

Multivariate analysis of factors influencing medical costs of acute pancreatitis hospitalizations based on a national administrative database.

BACKGROUND: Little information is available on the analysis of medical costs of acute pancreatitis hospitalizations. AIM: This study aimed to determine the factors affecting medical costs of patients with acute pancreatitis during hospitalization using a Japanese administrative database. METHODS: A total of 7193 patients with acute pancreatitis were referred to 776 hospitals. We defined "patients with high medical costs" as patients whose medical costs exceeded the 90th percentile in medical costs during hospitalization and identified the independent factors for patients with high medical costs with and without controlling for length of stay. RESULTS: Multiple logistic regression analysis demonstrated that necrosectomy was the most significant factor for medical costs of acute pancreatitis during hospitalization. The odds ratio of necrosectomy was 33.64 (95% confidence interval, 14.14-80.03; p<0.001). Use of an intensive care unit was the most significant factor for medical costs after controlling for LOS. The OR of an ICU was 6.44 (95% CI, 4.72-8.81; p<0.001). CONCLUSION: This study demonstrated that necrosectomy and use of an ICU significantly affected the medical costs of acute pancreatitis hospitalization. These results highlight the need for health care implementations to reduce medical costs whilst maintaining the quality of patient care, and targeting patients with severe acute pancreatitis.

A comparison of the hospital costs of open vs. minimally invasive surgical management of necrotizing pancreatitis.

BACKGROUND: Infected necrotizing pancreatitis is a major burden for both the patient and the health care system. Little is known about how hospital costs break down and how they may have shifted with the increasing use of minimally invasive techniques. The aim of this study was to analyse inpatient hospital costs associated with pancreatic necrosectomy. METHODS: A prospective database was used to identify all patients who underwent an intervention for necrotizing pancreatitis. Costs of treatment were calculated using detailed information from the Decision Support Department. Costs for open and minimally invasive surgical modalities were compared. RESULTS: Twelve open and 13 minimally invasive necrosectomies were performed in a cohort of 577 patients presenting over a 50-month period. One patient in each group died in hospital. Overall median stay was 3.8 days in the intensive care unit (ICU) and 44 days on the ward. The median overall treatment cost was US$ 56,674. The median largest contributors to this total were ward (26.3%), surgical personnel (22.3%) and ICU (17.0%) costs. These did not differ statistically between the two treatment modalities. CONCLUSIONS: Pancreatic necrosectomy uses considerable health care resources. Minimally invasive techniques have not been shown to reduce costs. Any intervention that can reduce the length of hospital and, in particular, ICU stay by reducing the incidence of organ failure or by preventing secondary infection is likely to be cost-effective.

[Importance of enteral nutrition support in necrotic hemorrhagic pancreatitis]. / Contributii la cunoasterea importantei suportului nutritional enteral în pancreatita acuta necrotico-hemoragica.

UNLABELLED: A clinical retrospec tive study was carried out on a series of 68 cases with acute pancreatitis, admitted in the General Surgery Department, Suceava County Hospital, between 2006-2009. RESULTS: A number of 50 men (73.5%) and 18 women (26.5%), aged between 29 and 69 was studied. Enteral nutrition (EN) with naso-jejunal tube placed by endoscopy was used in 55.8% of cases; naso-gastric tube in 20 patients; total parenteral nutrition (TPN) in 10 patients (14.7%). Average duration of nutrition was 15.5 days. Pancreatic complications were observed in 7 patients (70%) from the TPN group comparatively with only 11 (18.9%) in the EN group. There were no significant differences in mortality but significant in hospital costs. CONCLUSIONS: The EN support should be the preferred way of nutrition support in patients with acute pancreatitis, because it is associated with a lower incidence of infection and a reduced hospitalization.