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Practical Adherence to the Step-Up Approach for Pancreatic Necrosis: An Institutional Review

Vernissia Tam, Mazen Zenati, Chandraprakash Umapathy, Stephanie Downs-Canner, Ahmad Hamad, Amer H Zureikat, Kenneth K Lee, Herbert J Zeh III, Yadav Dhiraj, Melissa E Hogg

Context Infected pancreatic necrosis is traditionally approached with open necrosectomy. The 2010 randomized controlled PANTER trial proposed a “Step-Up” approach with fewer major complications, comparable mortality, and fewer operations. Objective We sought to evaluate the practical adherence to the Step-Up approach at a tertiary care institution. Design Retrospective, observational study comparing outcomes between patients treated in the “early” pre-PANTER trial period (2006-2010) and “late” post-trial period (2011- 2014). Setting Tertiary care, academic teaching hospital in Pittsburgh, PA. Patients Patients with suspected or proven infected pancreatic necrosis between 2006 and 2014. Interventions Percurtaneous or endoscopic drainage, surgery including open necrosectomy and videoassisted retroperitoneal debridement. Main Outcomes Adherence to the Step-Up approach, rates of intervention, long-term complications. Results Adherence to the Step-Up approach improved from 27% (25/75) to 46% (27/55) between the early to late periods (p<0.05). Late period patients had a higher rate of percutaneous drainage (65% vs. 43%, p=0.012) and higher median number of interventions (3 vs. 2, p<0.001), but comparable rates of surgery (73% vs. 79%, p=0.432). Rates of open necrosectomy decreased by 8%. Late patients had lower rates of both pancreatitis-related readmission (47% vs. 71%, p=0.007) and multiple readmissions (31% vs. 51%, p=0.024). Conclusions Overall, adherence to the SU improved, but remained below 50%. Compliance will likely require institutional support to enforce systembased clinical pathways and improve outcomes.