Safety of endoscopic pancreatic necrosectomy compared with percutaneous and surgical necrosectomy: a nationwide inpatient study

<b>Background and study aims</b> Pancreatic necrosis is an independent predictor of morbidity and mortality among patients with acute pancreatitis. We compared the safety and outcomes of three techniques including endoscopic necrosectomy, fluoroscopy-guided percutaneous necrosectomy by an interventional radiologist, and surgical necrosectomy. <b>Patients and methods</b> Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent pancreatic necrosectomy from 2016 to 2019. They were identified using the International Classification of Diseases, 10th Revision, Procedure Coding System. <b>Results:</b> Of the 2,281 patients meeting the selection criteria, the method of pancreatic necrosectomy was as follows: endoscopy (n = 672), percutaneous (n = 1,338), and surgery (n = 271). Compared to surgery, the rate of mortality was lowest for endoscopy (hazard ratio (HR) 0.27; 95 % CI 0.08-0.90; <i>P</i> = 0.033) followed by percutaneous (HR 0.44; 95 % CI, 0.20-0.98; <i>P</i> = 0.045). Endoscopy was associated with less post-procedure bleeding compared to percutaneous and surgical necrosectomy ( <i>P</i> < 0.001), as well as lower rates of post-procedure renal failure ( <i>P</i> < 0.001) and respiratory failure ( <i>P</i> = 0.002). Endoscopy was associated with average shorter lengths of stay and total hospital costs when compared with percutaneous and surgical approaches, respectively (20.1 vs 25.8 vs 38.3 days; <i>P</i> < 0.001) and ($ 57K vs $ 76K vs $ 123K; <i>P</i> < 0.001). <b>Conclusions</b> Endoscopic necrosectomy is associated with significantly lower risk of inpatient mortality, adverse events, length of stay, and cost when compared to percutaneous and surgical approaches.