S251 Contemporary Trends in the Management of Acute Necrotizing Pancreatitis: Changing Times?

Introduction: Acute necrotizing pancreatitis (ANP) is often associated with prolonged hospitalization and high mortality rates. The contemporary treatment paradigm has shifted away from open necrosectomies and towards step-up strategies that incorporate minimally invasive (MIS) approaches. However, it is unclear if this has translated to actual practice changes in the real world. This study aims to assess real-world practice patterns in the management of ANP. Methods: The New York and Florida state databases were used to identify patients diagnosed with ANP between 2016 and 2021. Patients were categorized into treatment groups of an open necrosectomy-first approach or a step-up approach, defined as patients first undergoing an MIS procedure with either a percutaneous, endoscopic, or laparoscopic approach. Hierarchal regression models were used to adjust for measured confounding, with fixed effects assigned to patient-level variables and random effects assigned to hospital-level identifiers. Results: We identified 1,180 patients with ANP; 104 (8.8%) underwent an open necrosectomy-first approach, whereas 1,076 (91.2%) underwent a step-up approach. Amongst those who underwent a step-up approach, only 18 patients (1.7%) eventually required an open necrosectomy after the initial MIS procedures. The proportion of patients who underwent an open necrosectomy-first approach steadily declined from 15.9% in 2016 to 6.3% in 2021, while the use of a step-up approach increased from 84.1% in 2016 to 93.7% in 2021 (P < 0.05. The median 1-year cumulative hospital charge was higher in the open necrosectomy-first group compared to the step-up group ($449,791 vs $338,679, P < 0.01). Patients in the open necrosectomy-first group had a longer median index hospital length of stay compared to the step-up group (24.0 days vs 15.0 days, P = 0.0006). Patients in the open necrosectomy-first group were also associated with a higher mortality rate compared to the step-up group (18.3% vs 10.2%, P = 0.01). Both findings were consistent on regression models adjusting for confounders. Conclusion: While a step-up approach for ANP is increasingly utilized, almost 10% of patients still undergo upfront open necrosectomy in contemporary years. Patients with ANP who undergo upfront necrosectomy were associated with longer hospital length of stay and higher mortality rates.