Endoscopic versus surgical treatment for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials

Abstract

Objective To compare outcomes of endoscopic and surgical treatment for infected necrotizing pancreatitis (INP) based on results of randomized controlled trials (RCT). Background Treatment of INP has changed in the last two decades with adoption of interventional, endoscopic and minimally invasive surgical procedures for drainage and necrosectomy. However, this relies mostly on observational studies. Methods We performed a systematic review following Cochrane and PRISMA guidelines and AMSTAR-2 criteria and searched CENTRAL, Medline and Web of Science. Randomized controlled trails that compared an endoscopic treatment to a surgical treatment for patients with infected walled-off necrosis and included one of the main outcomes were eligible for inclusion. The main outcomes were mortality and new onset multiple organ failure. Prospero registration ID: CRD42019126033 Results Three RCTs with 190 patients were included. Intention to treat analysis showed no difference in mortality. However, patients in the endoscopic group had statistically significant lower odds of experiencing new onset multiple organ failure (odds ratio (OR) confidence interval [CI] 0.31 [0.10, 0.98]) and were statistically less likely to suffer from perforations of visceral organs or enterocutaneous fistulae (OR [CI] 0.31 [0.10, 0.93]), and pancreatic fistulae (OR [CI] 0.09 [0.03, 0.28]). Patients with endoscopic treatment had a statistically significant lower mean hospital stay (Mean difference [CI] − 7.86 days [− 14.49, − 1.22]). No differences in bleeding requiring intervention, incisional hernia, exocrine or endocrine insufficiency or ICU stay were apparent. Overall certainty of evidence was moderate. Conclusion There seem to be possible benefits of endoscopic treatment procedure. Given the heterogenous procedures in the surgical group as well as the low amount of randomized evidence, further studies are needed to evaluate the combination of different approaches and appropriate timepoints for interventions.

The continuum of complications in survivors of necrotizing pancreatitis

“…As more minimally invasive approaches are utilized, intuitively a decrease in complications such as hernia will be observed. Minimally invasive approaches have been associated with equivalent or improved rates of pancreatic insufficiency after NP 47,49,50 However, the impact of evolving management strategies on complications, such as gastrointestinal fistula, pancreaticobiliary stricture, splanchnic vein thrombosis, chronic pancreatitis, and chronic pain, remain unknown. Investigation of novel management strategies should consider these complications in their evaluation.…”

Open necrosectomy is feasible as a last resort in selected cases with infected pancreatic necrosis: a case series and systematic literature review

“…Nevertheless, all these studies are difficult to compare for the variability of patient characteristics and differences between surgical interventions. Indeed, Haney et al [ 57 ] have highlighted differences concerning also drainage techniques, placement of nasocystic catheters, and irrigation of the cyst in the endoscopic procedures among different trials. Moreover, these recommendations do not take into account the large variability in expertise between centres with various techniques but highlighted the importance of an expert pool involvement of specialists composed of gastroenterologist, interventional radiologists, surgeons, and intensive care physicians that may improve the patient outcomes.…”

The role of endoscopic therapy in the minimally invasive management of pancreatic necrosis

“…A recent meta-analysis evaluating data from three randomized studies (n = 190 patients) compared (predominantly) minimally invasive surgery techniques to endoscopic therapy for infected pancreatic necrosis. An endoscopic approach was associated with a lower odds of new onset organ failure (odds ratio [OR], 0.31; confidence interval [CI], 010 to 0.093), pancreatic fistula (OR, 0.09; 95% CI, 0.03 to 0.28) and shorter length of hospital stay (–7.86 days; 95% CI, –14.49 to 1.22) without differences in mortality, complications or pancreatic insufficiency [ 22 ].…”