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Design We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis.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.
- minimally invasive
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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.