EGS P17 No beds available for transfer! Experience of life saving pancreatic necrosectomies at a non-pancreatic upper GI unit
Authors: Bhatti Sumbal , Evans Laith , Kumar Bhaskar 
Published: December 2022

Abstract

Background
Infected necrotising pancreatitis (NP) has a high mortality. NICE recommends necrotising pancreatitis be managed at specialist pancreatic centres due to its challenging nature. However, timely transfer of patients from non-specialist centres to tertiary pancreatic units can be limited by critical bed availability. This problem is further compounded by the staffing issues and constraints on critical care facilities since the COVID19 pandemic. This situation places patients at high risk of mortality and poses the question as to whether lifesaving intervention can be offered within appropriate local upper GI non pancreatic units. We present our data from emergent pancreatic necrosectomies in a sub-set of critically ill patients for whom transfer to specialist care was not possible due to lack of availability of critical care beds.

Methods
A retrospective case series is presented over a two-year period at a non-pancreatic upper GI centre. Patients over a two-year period (2020–2022) were identified using clinical coding and operation note records. Data was collected on patient characteristics such as age, gender, and co-morbidities, as well as on their inflammatory markers on presentation, imaging modality used, nutritional status and duration of care in a high dependency unit. Complications, including death following pancreatic necrosectomy were also recorded.
Only descriptive statistics were used in this audit. No advanced statistics were required. Data standards were assessed using fractions and then percentages for ease of understanding.

Results
A total of six patients were identified as having undergone emergency pancreatic necrosectomies. Patients included were all male with a mean age of 48 and an average BMI of 25.6. The mean number of days patients were in hospital prior to their necrosectomy was 42.6. On average patients had 5.5 CT scans prior to their necrosectomy. 50% of patients had organ failure requiring ventilatory support and/or hemofiltration.
Comorbidities included diabetes mellitus, rheumatoid arthritis and Covid-19. Social factors such as excess alcohol consumption and cigarette smoking were also present.
As per NICE guidance, 100% of patients were administered enteral nutrition through a nasojejunal tube during their admission. 50% of patients received parenteral nutrition after failure of enteral nutrition, in keeping with best practice.
100% underwent a pancreatic necrosectomy and 50% had further operations. The mean number of re-operations per patient was 2.3. The average number of days between admission and pancreatic necrosectomy was 42 days.
100% of patients had complications with 50% suffering from AKI and 33% patients were readmitted with pancreatitis related complications. One death was from post operative haemorrhage.
Overall survival rate at this tertiary care centre was 83.3%. These patients are currently still being followed up.

Conclusions
The results of our audit have shown that necrotising pancreatitis can be managed outside of a specialist pancreatic centre providing there are appropriately skilled surgeons and critical care staff employed, who are confident in managing the condition.
Complications at the centre, including death rates, were no higher than reported in the literature, suggesting patient safety was not adversely affected.
Ideally, further audits will need to be carried out on a larger scale, potentially with multiple trusts involved, comparing specialist pancreatic centres to non-specialist facilities to ensure that the results of our audit are not limited to this tertiary care centre alone.
The data in this audit stems from during the Covid-19 pandemic and therefore additional auditing will need to be done in case the pressures of the pandemic on healthcare services has impacted upon the results and findings, as well as the patient cohort.