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Original Article
Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients
  1. Sandra van Brunschot1,
  2. Robbert A Hollemans2,3,
  3. Olaf J Bakker4,
  4. Marc G Besselink2,
  5. Todd H Baron5,
  6. Hans G Beger6,
  7. Marja A Boermeester2,
  8. Thomas L Bollen7,
  9. Marco J Bruno8,
  10. Ross Carter9,
  11. Jeremy J French10,
  12. Djalma Coelho11,
  13. Björn Dahl12,
  14. Marcel G Dijkgraaf13,
  15. Nilesh Doctor14,
  16. Peter J Fagenholz15,
  17. Gyula Farkas16,
  18. Carlos Fernandez del Castillo15,
  19. Paul Fockens1,
  20. Martin L Freeman17,
  21. Timothy B Gardner18,
  22. Harry van Goor19,
  23. Hein G Gooszen20,
  24. Gerjon Hannink21,
  25. Rajiv Lochan10,
  26. Colin J McKay9,
  27. John P Neoptolemos22,
  28. Atilla Oláh23,
  29. Rowan W Parks24,
  30. Miroslav P Peev15,
  31. Michael Raraty22,
  32. Bettina Rau25,
  33. Thomas Rösch26,
  34. Maroeska Rovers20,
  35. Hans Seifert12,
  36. Ajith K Siriwardena27,
  37. Karen D Horvath28,
  38. Hjalmar C van Santvoort4,29
  1. 1Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
  2. 2Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
  3. 3Department of Research and Development, St Antonius Hospital, Nieuwegein, The Netherlands
  4. 4Department of Surgery, University Medical Center Utrecht, Utrecht
  5. 5Department of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
  6. 6Department of Surgery, University of Ulm, Ulm, Germany
  7. 7Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands
  8. 8Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
  9. 9West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
  10. 10Department of Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
  11. 11Department of Surgery, Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
  12. 12Department of Internal Medicine, Oldenburg Municipal Hospital, Oldenburg, Germany
  13. 13Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
  14. 14Department of Gastrointestinal Surgery, Jaslok Hospital and Research Center, Mumbai, India
  15. 15Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  16. 16Department of Surgery, University of Szeged, Szeged, Hungary
  17. 17Department of Gastroenterology, University of Minnesota, Minneapolis, Minnesota, USA
  18. 18Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire, USA
  19. 19Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
  20. 20Operating Rooms-Evidence Based Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
  21. 21Orthopaedic Research Lab, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
  22. 22Clinical Directorate of General Surgery, National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
  23. 23Department of Surgery, Petz-Aladár Teaching Hospital, Györ, Hungary
  24. 24Department of Surgery, University of Edinburgh, Edinburgh, UK
  25. 25Department of Surgery, University of Rostock, Rostock, Germany
  26. 26Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
  27. 27Department of Surgery, Manchester Royal Infirmary, Manchester, UK
  28. 28Department of Surgery, University of Washington, Seattle, USA
  29. 29Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
  1. Correspondence to mr. Hjalmar C van Santvoort, Department of Surgery, Dutch Acute Pancreatitis Study Group, University Medical Center Utrecht 3508 GA/ St. Antonius Hospital Nieuwegein 3435 CM, The Netherlands; h.vanSantvoort{at}umcutrecht.nl

Abstract

Objective Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking.

Design We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%).

Results Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005).

Conclusion In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.

  • pancreatitis
  • necrosis
  • surgery
  • minimally invasive
  • endoscopy

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Footnotes

  • SB and RAH are shared first author.

  • Contributors Study concept and design: RAH, OJB, SvB, MGB, MAB, MGD, HGG, GH, KDH, HCvS. Acquisition of data: OJB, MGB, THB, HGB, MAB, TLB, MJB, SvB, RC, RMC, DC, BD, ND, GF, PJF, CF-dC, PF, MLF, TBG, HvG, HGG, RAH, RL, CJM, MPP, JPN, AO, RWP, MR, BR, TR, HS, AKS, KDH, HCvS. Analysis and interpretation of data: OJB, SvB, MGD, GH, RAH, MR, HCvS. Drafting of the manuscript: OJB, SvB, RAH, KDH, HCvS. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: SvB, MGD, GH, RAH, HCvS. Study supervision: HCvS.

  • Funding Dutch Digestive Disease Foundation. Role of the sponsor: The sponsor did not play any role in concept and design, statistical analysis, interpretation of the data, writing of the manuscript or decision to submit the manuscript. The researchers were fully independent from the funder.

  • Competing interests All authors declare no support from any organisation for the submitted work, no financial relationships with any organisation that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work.

  • Ethics approval The institutional review boards of the participating centres approved study protocols, if appropriate.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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