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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. 1 Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
  2. 2 Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
  3. 3 Department of Research and Development, St Antonius Hospital, Nieuwegein, The Netherlands
  4. 4 Department of Surgery, University Medical Center Utrecht, Utrecht
  5. 5 Department of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
  6. 6 Department of Surgery, University of Ulm, Ulm, Germany
  7. 7 Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands
  8. 8 Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
  9. 9 West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
  10. 10 Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
  11. 11 Department of Surgery, Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
  12. 12 Department of Internal Medicine, Oldenburg Municipal Hospital, Oldenburg, Germany
  13. 13 Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
  14. 14 Department of Gastrointestinal Surgery, Jaslok Hospital and Research Center, Mumbai, India
  15. 15 Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  16. 16 Department of Surgery, University of Szeged, Szeged, Hungary
  17. 17 Department of Gastroenterology, University of Minnesota, Minneapolis, Minnesota, USA
  18. 18 Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire, USA
  19. 19 Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
  20. 20 Operating Rooms-Evidence Based Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
  21. 21 Orthopaedic Research Lab, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
  22. 22 Clinical 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. 23 Department of Surgery, Petz-Aladár Teaching Hospital, Györ, Hungary
  24. 24 Department of Surgery, University of Edinburgh, Edinburgh, UK
  25. 25 Department of Surgery, University of Rostock, Rostock, Germany
  26. 26 Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
  27. 27 Department of Surgery, Manchester Royal Infirmary, Manchester, UK
  28. 28 Department of Surgery, University of Washington, Seattle, USA
  29. 29 Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
  1. Correspondence to 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}


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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  • 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.

  • Correction notice This article has been corrected since it published Online First. The footnotes in tables 1 and 2 have been corrected.

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