Year 2019 / Volume 111 / Number 6
Review
An endoscopic or minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis

471-480

DOI: 10.17235/reed.2019.5792/2018

Yong Hu, Chunyan Li, Xin Zhao, Yunfeng Cui,

Abstract
Background and aim: the incidence of acute pancreatitis is rising across the world, thus further increasing the burden on healthcare services. Approximately 10% of patients with acute pancreatitis will develop infected necrotizing pancreatitis (INP), which is the leading cause of high mortality in the late phase. There is currently no consensus with regard to the use of endoscopic or minimally invasive surgery as the first-line therapy of choice for INP. However, more clinical research with regard to the superiority of an endoscopic approach has been recently published. Therefore, we conducted a systematic review and meta-analysis to determine which of the two treatments leads to a better prognosis. Methods: four databases (Medline, SINOMED, EMBASE and Cochrane Library) were searched for eligible studies from 1980 to 2018, comparing endoscopic and minimally invasive surgery for INP. Results: two randomized controlled trials (RCTs) and seven clinical cohort studies were included. After the analysis of data amenable to polling, significant advantages were found in favor of the endoscopic approach in terms of pancreatic fistulas (OR = 0.10, 95% CI 0.04-0.30, p < 0.001) and the length of hospital stay (weighted mean difference [WMD] = -24.72, 95% CI = -33.87 to -15.57, p < 0.001). No marked differences were found in terms of mortality, multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, recurrence of pseudocysts, and length of stay (LOS) in the Intensive Care Unit (ICU), endocrine insufficiency and exocrine insufficiency. Conclusion: compared with minimally invasive surgery, an endoscopic approach evidently improved short-term outcomes for infected necrotizing pancreatitis, including pancreatic fistula and the length of hospital stay. Furthermore, relevant multicenter RCTs are eager to validate these findings.
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References
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2. Das S, Mahakkanukrauh P and Ho CC. The Burden of Gastrointestinal, Liver, and Pancreatic Diseases: The Global Scenario. Gastroenterology. 2016; 150:1045-6.
3. Banks PA, Bollen TL and Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2012; 62:102-11.
4. Lerch MM. Classifying an unpredictable disease: the revised Atlanta classification of acute pancreatitis. Gut. 2013; 62:2-3.
5. Lankisch PG, Apte M and Banks PA. Acute pancreatitis. Lancet. 2015; 386:85-96.
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29. Malka D, Hammel P and Sauvanet A, et al. Risk factors for diabetes mellitus in chronic pancreatitis. Gastroenterology. 2000; 119:1324-32.
30. Shen HN, Yang CC, Chang YH, Lu CL and Li CY. Risk of Diabetes Mellitus after First-Attack Acute Pancreatitis: A National Population-Based Study. Am J Gastroenterol. 2015; 110:1698-706.
31. Bradley EL and Dexter ND. Management of Severe Acute Pancreatitis. Ann Surg. 2010; 251:6-17.
32. Babu BI, Sheen AJ, Lee SH, O'Shea S, Eddleston JM and Siriwardena AK. Open pancreatic necrosectomy in the multidisciplinary management of postinflammatory necrosis. Ann Surg. 2010; 251:783-6.
33. Heinrich S, Schafer M, Rousson V and Clavien PA. Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg. 2006; 243:154-68.
34. Gomatos IP, Halloran CM and Ghaneh P, et al. Outcomes From Minimal Access Retroperitoneal and Open Pancreatic Necrosectomy in 394 Patients With Necrotizing Pancreatitis. Ann Surg. 2016; 263:992-1001.
35. Steinberg WM. A step-up approach, or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010; 363:1286-7.
36. Wronski M, Cebulski W and Witkowski B, et al. Comparison between minimally invasive and open surgical treatment in necrotizing pancreatitis. J Surg Res. 2017; 210:22-31.
37. Tu Y, Jiao H, Tan X, Sun L and Zhang W. Laparotomy versus retroperitoneal laparoscopy in debridement and drainage of retroperitoneal infected necrosis in severe acute pancreatitis. Surg Endoscopy. 2013; 27:4217-23.
38. Raraty MGT, Halloran CM and Dodd S, et al. Minimal Access Retroperitoneal Pancreatic Necrosectomy. Ann Surg. 2010; 251:787-93.
39. Boumitri C, Brown E and Kahaleh M. Necrotizing Pancreatitis: Current Management and Therapies. Clin Endosc. 2017; 50:357-65.
40. Roch AM, Maatman T and Carr RA, et al. Evolving treatment of necrotizing pancreatitis. Am J Surg. 2018; 215:526-9.
41. Sterne JA, Sutton AJ and Ioannidis JP, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ. 2011; 343:d4002.
42. Lau J, Ioannidis JP, Terrin N, Schmid CH and Olkin I. The case of the misleading funnel plot. BMJ. 2006; 333:597-600.
1. Vege SS, DiMagno MJ, Forsmark CE, Martel M and Barkun AN. Initial Medical Treatment of Acute Pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology. 2018; 154:1103-39.
2. Das S, Mahakkanukrauh P and Ho CC. The Burden of Gastrointestinal, Liver, and Pancreatic Diseases: The Global Scenario. Gastroenterology. 2016; 150:1045-6.
3. Banks PA, Bollen TL and Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2012; 62:102-11.
4. Lerch MM. Classifying an unpredictable disease: the revised Atlanta classification of acute pancreatitis. Gut. 2013; 62:2-3.
5. Lankisch PG, Apte M and Banks PA. Acute pancreatitis. Lancet. 2015; 386:85-96.
6. Sanjay P, Yeeting S, Whigham C, Judson H, Polignano FM and Tait IS. Endoscopic sphincterotomy and interval cholecystectomy are reasonable alternatives to index cholecystectomy in severe acute gallstone pancreatitis (GSP). Surgical Endoscopy. 2008; 22:1832-7.
7. Wan J, Ouyang Y, Yu C, Yang X, Xia L and Lu N. Comparison of EUS with MRCP in idiopathic acute pancreatitis: a systematic review and meta-analysis. Gastrointest Endosc. 2018; 87:1180-8.
8. Said M and Rongen A. Can Laparoscopic Cholecystectomy Prevent Recurrent Idiopathic Acute Pancreatitis? Ann Surg. 2017; 266:e94-5.
9. van Santvoort HC, Bakker OJ and Bollen TL, et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology. 2011; 141:1254-63.
10. van Dijk SM, Hallensleben NDL and van Santvoort HC, et al. Acute pancreatitis: recent advances through randomised trials. Gut. 2017; 66:2024-32.
11. Banks PA and Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol. 2006; 101:2379-400.
12. Hecker M, Mayer K and Askevold I, et al. [Acute pancreatitis]. Anaesthesist. 2014; 63:253-63.
13. van Santvoort HC, Besselink MG and Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010; 362:1491-502.
14. Kokosis G, Perez A and Pappas TN. Surgical management of necrotizing pancreatitis: an overview. World J Gastroenterol. 2014; 20:16106-12.
15. Aparna D, Kumar S and Kamalkumar S. Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach: 7 years experience from a single surgical unit. World Journal of Gastrointestinal Surgery. 2017; 9:200-8.
16. Hozo SP, Djulbegovic B and Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. Bmc Med Res Methodol. 2005; 5:13.
17. van Brunschot S, van Grinsven J and van Santvoort HC, et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. The Lancet. 2018; 391:51-8.
18. Bakker OJ, van Santvoort HC and van Brunschot S, et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012; 307:1053-61.
19. He W, Zhu Y and Zhu Y, et al. The outcomes of initial endoscopic transluminal drainage are superior to percutaneous drainage for patients with infected pancreatic necrosis: a prospective cohort study. Surg Endoscopy. 2017; 31:3004-13.
20. Kumar N, Conwell DL and Thompson CC. Direct Endoscopic Necrosectomy Versus Step-Up Approach for Walled-Off Pancreatic Necrosis. Pancreas. 2014; 43:1334-1339.
21. Woo S, Walklin R, Wewelwala C, Berry R, Devonshire D and Croagh D. Interventional management of necrotizing pancreatitis: an Australian experience. 2017; 87:E85-9.
22. Khreiss M, Zenati M and Clifford A, et al. Cyst Gastrostomy and Necrosectomy for the Management of Sterile Walled-Off Pancreatic Necrosis: a Comparison of Minimally Invasive Surgical and Endoscopic Outcomes at a High-Volume Pancreatic Center. J Gastrointest Surg. 2015; 19:1441-8.
23. Bausch D, Wellner U and Kahl S, et al. Minimally invasive operations for acute necrotizing pancreatitis: Comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy. Surgery. 2012; 152:S128-34.
24. Tan V, Charachon A and Lescot T, et al. Endoscopic transgastric versus surgical necrosectomy in infected pancreatic necrosis. Clin Res Hepatol Gastroenterol. 2014; 38:770-76.
25. Gluck M, Ross A and Irani S, et al. Endoscopic and Percutaneous Drainage of Symptomatic Walled-Off Pancreatic Necrosis Reduces Hospital Stay and Radiographic Resources. Clinical Gastroenterology and Hepatology. 2010; 8: 1083-88.
26. Alali A, Mosko J, May G and Teshima C. Endoscopic Ultrasound-Guided Management of Pancreatic Fluid Collections: Update and Review of the Literature. Clinical Endoscopy. 2017; 50:117-25.
27. Isayama H, Nakai Y and Rerknimitr R, et al. Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment. J Gastroenterol Hepatol. 2016; 31:1546-54.
28. Braden B and Dietrich CF. Endoscopic ultrasonography-guided endoscopic treatment of pancreatic pseudocysts and walled-off necrosis: New technical developments. World J Gastroenterol. 2014; 20:16191.
29. Hines OJ and Donald GW. Endoscopic transgastric necrosectomy for infected necrotizing pancreatitis. JAMA. 2012; 307:1084-5.
30. Fagenholz PJ and Fernandez-del CC. Necrosectomy for infected necrotizing pancreatitis. JAMA. 2012; 307:2584, 2584-5.
31. Malka D, Hammel P and Sauvanet A, et al. Risk factors for diabetes mellitus in chronic pancreatitis. Gastroenterology. 2000; 119:1324-32.
32. Shen HN, Yang CC, Chang YH, Lu CL and Li CY. Risk of Diabetes Mellitus after First-Attack Acute Pancreatitis: A National Population-Based Study. Am J Gastroenterol. 2015; 110:1698-706.
33. Bradley EL and Dexter ND. Management of Severe Acute Pancreatitis. Ann Surg. 2010; 251:6-17.
34. Babu BI, Sheen AJ, Lee SH, O'Shea S, Eddleston JM and Siriwardena AK. Open pancreatic necrosectomy in the multidisciplinary management of postinflammatory necrosis. Ann Surg. 2010; 251:783-6.
35. Heinrich S, Schafer M, Rousson V and Clavien PA. Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg. 2006; 243:154-68.
36. Gomatos IP, Halloran CM and Ghaneh P, et al. Outcomes From Minimal Access Retroperitoneal and Open Pancreatic Necrosectomy in 394 Patients With Necrotizing Pancreatitis. Ann Surg. 2016; 263:992-1001.
37. Steinberg WM. A step-up approach, or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010; 363:1286-7.
38. Wronski M, Cebulski W and Witkowski B, et al. Comparison between minimally invasive and open surgical treatment in necrotizing pancreatitis. J Surg Res. 2017; 210:22-31.
39. Tu Y, Jiao H, Tan X, Sun L and Zhang W. Laparotomy versus retroperitoneal laparoscopy in debridement and drainage of retroperitoneal infected necrosis in severe acute pancreatitis. Surg Endoscopy. 2013; 27:4217-23.
40. Raraty MGT, Halloran CM and Dodd S, et al. Minimal Access Retroperitoneal Pancreatic Necrosectomy. Ann Surg. 2010; 251:787-93.
41. Boumitri C, Brown E and Kahaleh M. Necrotizing Pancreatitis: Current Management and Therapies. Clin Endosc. 2017; 50:357-65.
42. Roch AM, Maatman T and Carr RA, et al. Evolving treatment of necrotizing pancreatitis. Am J Surg. 2018; 215:526-9.
43. Sterne JA, Sutton AJ and Ioannidis JP, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ. 2011; 343:d4002.
44. Lau J, Ioannidis JP, Terrin N, Schmid CH and Olkin I. The case of the misleading funnel plot. BMJ. 2006; 333:597-600.
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Publication history

Received: 24/06/2018

Accepted: 29/11/2018

Online First: 25/04/2019

Published: 07/06/2019

Article revision time: 153 days

Article Online First time: 305 days

Article editing time: 348 days


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