Advertisement

Surgical Endoscopy

, Volume 28, Issue 5, pp 1425–1438 | Cite as

Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review

  • Sandra van BrunschotEmail author
  • Paul Fockens
  • Olaf J. Bakker
  • Marc G. Besselink
  • Rogier P. Voermans
  • Jan-Werner Poley
  • Hein G. Gooszen
  • Marco Bruno
  • Hjalmar C. van Santvoort
Review

Abstract

Objective

We performed a systematic review to assess the outcome of endoscopic transluminal necrosectomy in necrotising pancreatitis with additional focus on indication, disease severity, and methodological quality of studies.

Design

We searched the literature published between January 2005 and June 2013. Cohorts, including patients with (infected) necrotising pancreatitis, undergoing endoscopic necrosectomy were included. Indication, disease severity, and methodological quality were described. The main outcomes were mortality, major complications, number of endoscopic sessions, and definitive successful treatment with endoscopic necrosectomy alone.

Results

After screening 581 papers, 14 studies, including 455 patients, fulfilled the eligibility criteria. All included studies were retrospective analyses except for one randomized, controlled trial. Overall methodological quality was moderate to low (mean 5, range 2–9). Less than 50 % of studies reported on pre-procedural severity of disease: mean APACHE-II score before intervention was 8; organ failure was present in 23 % of patients; and infected necrosis in 57 % of patients. On average, four (range 1–23) endoscopic interventions were performed per patient. With endoscopic necrosectomy alone, definitive successful treatment was achieved in 81 % of patients. Mortality was 6 % (28/460 patients) and complications occurred in 36 % of patients. Bleeding was the most common complication.

Conclusions

Endoscopic transluminal necrosectomy is an effective treatment for the majority of patients with necrotising pancreatitis with acceptable mortality and complication rates. It should be noted that methodological quality of the available studies is limited and that the combined patient population of endoscopically treated patients is only moderately ill.

Keywords

Necrotising pancreatitis Endoscopy Intervention Necrosectomy Systematic 

Notes

Disclosures

No potential conflict of interest relevant to this article was reported.

Funding

Sandra van Brunschot is sponsored by the Dutch Maag Lever Darm Stichting (MLDS) and Fonds Nuts Ohra to perform a randomized, controlled clinical trial on necrotising pancreatitis. The sponsors had no involvement in any stage of the study design, data collection, data-analysis, and interpretation of the study results.

References

  1. 1.
    van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ahmed Ali U, Schrijver AM, Boermeester MA, van Goor H, Dejong CH, van Eijck CH, van Ramshorst B, Schaapherder AF, van der Harst E, Hofker S, Nieuwenhuijs VB, Brink MA, Kruyt PM, Manusama ER, van der Schelling GP, Karsten T, Hesselink EJ, van Laarhoven CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP, Cuesta MA, Wahab PJ, Gooszen HG (2011) A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 141:1254–1263PubMedCrossRefGoogle Scholar
  2. 2.
    Besselink MG, van Santvoort HC, Buskens E, Boermeester MA, van Goor H, Timmerman HM, Nieuwenhuijs VB, Bollen TL, van Ramshorst B, Witteman BJ, Rosman C, Ploeg RJ, Brink MA, Schaapherder AF, Dejong CH, Wahab PJ, van Laarhoven CJ, van der Harst E, van Eijck CH, Cuesta MA, Akkermans LM, Gooszen HG (2008) Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. Lancet 371:651–659PubMedCrossRefGoogle Scholar
  3. 3.
    Besselink MG, van Santvoort HC, Nieuwenhuijs VB, Boermeester MA, Bollen TL, Buskens E, Dejong CH, van Eijck CH, van Goor H, Hofker SS, Lameris JS, van Leeuwen MS, Ploeg RJ, van Ramshorst B, Schaapherder AF, Cuesta MA, Consten EC, Gouma DJ, van der Harst E, Hesselink EJ, Houdijk LP, Karsten TM, van Laarhoven CJ, Pierie JP, Rosman C, Bilgen EJ, Timmer R, van der Tweel I, de Wit RJ, Witteman BJ, Gooszen HG (2006) Minimally invasive ‘step-up approach’ versus maximal necrosectomy in patients with acute necrotising pancreatitis (PANTER trial): design and rationale of a randomised controlled multicenter trial [ISRCTN13975868]. BMC Surg 6:6PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Raraty MG, Halloran CM, Dodd S, Ghaneh P, Connor S, Evans J, Sutton R, Neoptolemos JP (2010) Minimal access retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg 251:787–793PubMedCrossRefGoogle Scholar
  5. 5.
    Rodriguez JR, Razo AO, Targarona J, Thayer SP, Rattner DW, Warshaw AL, Fernandez-del Castillo C (2008) Debridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 247:294–299PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, van Goor H, Schaapherder AF, van Eijck CH, Bollen TL, van Ramshorst B, Nieuwenhuijs VB, Timmer R, Lameris JS, Kruyt PM, Manusama ER, van der Harst E, van der Schelling GP, Karsten T, Hesselink EJ, van Laarhoven CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP, van Leeuwen MS, Buskens E, Gooszen HG (2010) A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 362:1491–1502PubMedCrossRefGoogle Scholar
  7. 7.
    Ashley SW, Perez A, Pierce EA, Brooks DC, Moore FD Jr, Whang EE, Banks PA, Zinner MJ (2001) Necrotizing pancreatitis: contemporary analysis of 99 consecutive cases. Ann Surg 234:572–579 discussion 579–580PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Babu BI, Sheen AJ, Lee SH, O’Shea S, Eddleston JM, Siriwardena AK (2010) Open pancreatic necrosectomy in the multidisciplinary management of postinflammatory necrosis. Ann Surg 251:783–786PubMedCrossRefGoogle Scholar
  9. 9.
    Buchler MW, Gloor B, Muller CA, Friess H, Seiler CA, Uhl W (2000) Acute necrotizing pancreatitis: treatment strategy according to the status of infection. Ann Surg 232:619–626PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Connor S, Alexakis N, Raraty MG, Ghaneh P, Evans J, Hughes M, Garvey CJ, Sutton R, Neoptolemos JP (2005) Early and late complications after pancreatic necrosectomy. Surgery 137:499–505PubMedCrossRefGoogle Scholar
  11. 11.
    Howard TJ, Patel JB, Zyromski N, Sandrasegaran K, Yu J, Nakeeb A, Pitt HA, Lillemoe KD (2007) Declining morbidity and mortality rates in the surgical management of pancreatic necrosis. J Gastrointest Surg 11:43–49PubMedCrossRefGoogle Scholar
  12. 12.
    Rau B, Bothe A, Beger HG (2005) Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing patient characteristics and outcome in a 19-year, single-center series. Surgery 138:28–39PubMedCrossRefGoogle Scholar
  13. 13.
    Tsiotos GG, Luque-de Leon E, Sarr MG (1998) Long-term outcome of necrotizing pancreatitis treated by necrosectomy. Br J Surg 85:1650–1653PubMedCrossRefGoogle Scholar
  14. 14.
    Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL, van Eijck CH, Fockens P, Hazebroek EJ, Nijmeijer RM, Poley JW, van Ramshorst B, Vleggaar FP, Boermeester MA, Gooszen HG, Weusten BL, Timmer R (2012) Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 307:1053–1061PubMedCrossRefGoogle Scholar
  15. 15.
    Seifert H, Wehrmann T, Schmitt T, Zeuzem S, Caspary WF (2000) Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 356:653–655PubMedCrossRefGoogle Scholar
  16. 16.
    Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. Open Med 3:e123–e130PubMedCentralPubMedGoogle Scholar
  17. 17.
    Bradley EL III (1993) A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11–13, 1992. Arch Surg 128:586–590PubMedCrossRefGoogle Scholar
  18. 18.
    Downs SH, Black N (1998) The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 52:377–384PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73:712–716PubMedCrossRefGoogle Scholar
  20. 20.
    Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH (1990) Acute pancreatitis: value of CT in establishing prognosis. Radiology 174:331–336PubMedGoogle Scholar
  21. 21.
    Mortele KJ, Wiesner W, Intriere L, Shankar S, Zou KH, Kalantari BN, Perez A, vanSonnenberg E, Ros PR, Banks PA, Silverman SG (2004) A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. AJR Am J Roentgenol 183:1261–1265PubMedCrossRefGoogle Scholar
  22. 22.
    Balthazar EJ, Ranson JH, Naidich DP, Megibow AJ, Caccavale R, Cooper MM (1985) Acute pancreatitis: prognostic value of CT. Radiology 156:767–772PubMedGoogle Scholar
  23. 23.
    Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558PubMedCrossRefGoogle Scholar
  25. 25.
    Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Abdelhafez M, Elnegouly M, Hasab Allah MS, Elshazli M, Mikhail HM, Yosry A (2013) Transluminal retroperitoneal endoscopic necrosectomy with the use of hydrogen peroxide and without external irrigation: a novel approach for the treatment of walled-off pancreatic necrosis. Surgical Endosc 27(10):3911–3920CrossRefGoogle Scholar
  27. 27.
    Bausch D, Wellner U, Kahl S, Kuesters S, Richter-Schrag HJ, Utzolino S, Hopt UT, Keck T, Fischer A (2012) Minimally invasive operations for acute necrotizing pancreatitis: comparison of minimally invasive retroperitoneal necrosectomy with endoscopic transgastric necrosectomy. Surgery 152:S128–S134PubMedCrossRefGoogle Scholar
  28. 28.
    Charnley RM, Lochan R, Gray H, O’Sullivan CB, Scott J, Oppong KE (2006) Endoscopic necrosectomy as primary therapy in the management of infected pancreatic necrosis. Endoscopy 38:925–928PubMedCrossRefGoogle Scholar
  29. 29.
    Coelho D, Ardengh JC, Eulalio JM, Manso JE, Monkemuller K, Coelho JF (2008) Management of infected and sterile pancreatic necrosis by programmed endoscopic necrosectomy. Dig Dis 26:364–369PubMedCrossRefGoogle Scholar
  30. 30.
    Escourrou J, Shehab H, Buscail L, Bournet B, Andrau P, Moreau J, Fourtanier G (2008) Peroral transgastric/transduodenal necrosectomy: success in the treatment of infected pancreatic necrosis. Ann Surg 248:1074–1080PubMedCrossRefGoogle Scholar
  31. 31.
    Gardner TB, Chahal P, Papachristou GI, Vege SS, Petersen BT, Gostout CJ, Topazian MD, Takahashi N, Sarr MG, Baron TH (2009) A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis. Gastrointest Endosc 69:1085–1094PubMedCrossRefGoogle Scholar
  32. 32.
    Gardner TB, Coelho-Prabhu N, Gordon SR, Gelrud A, Maple JT, Papachristou GI, Freeman ML, Topazian MD, Attam R, Mackenzie TA, Baron TH (2011) Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 73:718–726PubMedCrossRefGoogle Scholar
  33. 33.
    Papachristou GI, Takahashi N, Chahal P, Sarr MG, Baron TH (2007) Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg 245:943–951PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Rische S, Riecken B, Degenkolb J, Kayser T, Caca K (2013) Transmural endoscopic necrosectomy of infected pancreatic necroses and drainage of infected pseudocysts: a tailored approach. Scand J Gastroenterol 48:231–240PubMedCrossRefGoogle Scholar
  35. 35.
    Schrover IM, Weusten BL, Besselink MG, Bollen TL, van Ramshorst B, Timmer R (2008) EUS-guided endoscopic transgastric necrosectomy in patients with infected necrosis in acute pancreatitis. Pancreatology 8:271–276PubMedCrossRefGoogle Scholar
  36. 36.
    Seewald S, Groth S, Omar S, Imazu H, Seitz U, de Weerth A, Soetikno R, Zhong Y, Sriram PV, Ponnudurai R, Sikka S, Thonke F, Soehendra N (2005) Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos). Gastrointest Endosc 62:92–100PubMedCrossRefGoogle Scholar
  37. 37.
    Seifert H, Biermer M, Schmitt W, Jurgensen C, Will U, Gerlach R, Kreitmair C, Meining A, Wehrmann T, Rosch T (2009) Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 58:1260–1266PubMedCrossRefGoogle Scholar
  38. 38.
    Voermans RP, Veldkamp MC, Rauws EA, Bruno MJ, Fockens P (2007) Endoscopic transmural debridement of symptomatic organized pancreatic necrosis (with videos). Gastrointest Endosc 66:909–916PubMedCrossRefGoogle Scholar
  39. 39.
    Gurusamy KS, Farouk M, Tweedie JH (2005) UK guidelines for the management of acute pancreatitis. Gut 54(Suppl 3):1–9Google Scholar
  40. 40.
    Forsmark CE, Baillie J (2007) AGA Institute technical review on acute pancreatitis. Gastroenterology 132:2022–2044PubMedCrossRefGoogle Scholar
  41. 41.
    American Gastroenterological Association (AGA) Institute on “Management of Acute Pancreatits” Clinical Practice and Economics Committee, AGA Institute Governing Board (2007) AGA Institute medical position statement on acute pancreatitis. Gastroenterology 132:2019–2021CrossRefGoogle Scholar
  42. 42.
    Banks PA, Freeman ML (2006) Practice guidelines in acute pancreatitis. Am J Gastroenterol 101:2379–2400PubMedCrossRefGoogle Scholar
  43. 43.
    Uhl W, Warshaw A, Imrie C, Bassi C, McKay CJ, Lankisch PG, Carter R, Di Magno E, Banks PA, Whitcomb DC, Dervenis C, Ulrich CD, Satake K, Ghaneh P, Hartwig W, Werner J, McEntee G, Neoptolemos JP, Buchler MW (2002) IAP Guidelines for the Surgical Management of Acute Pancreatitis. Pancreatology 2:565–573PubMedCrossRefGoogle Scholar
  44. 44.
    Walser EM, Nealon WH, Marroquin S, Raza S, Hernandez JA, Vasek J (2006) Sterile fluid collections in acute pancreatitis: catheter drainage versus simple aspiration. Cardiovasc Intervent Radiol 29:102–107PubMedCrossRefGoogle Scholar
  45. 45.
    Zerem E, Imamovic G, Omerovic S, Imsirovic B (2009) Randomized controlled trial on sterile fluid collections management in acute pancreatitis: should they be removed? Surg Endosc 23:2770–2777PubMedCrossRefGoogle Scholar
  46. 46.
    van Brunschot S, Besselink MG, Bakker OJ, Boermeester MA, Gooszen HG, Horvath KD, van Santvoort HC (2013) Video-assisted retroperitoneal debridement (VARD) of infected necrotizing pancreatitis: an update. Curr Surg Rep 1:121–130CrossRefGoogle Scholar
  47. 47.
    Strom T, Martinussen T, Toft P (2010) A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 375:475–480PubMedCrossRefGoogle Scholar
  48. 48.
    Barkun JS, Aronson JK, Feldman LS, Maddern GJ, Strasberg SM, Altman DG, Blazeby JM, Boutron IC, Campbell WB, Clavien PA, Cook JA, Ergina PL, Flum DR, Glasziou P, Marshall JC, McCulloch P, Nicholl J, Reeves BC, Seiler CM, Meakins JL, Ashby D, Black N, Bunker J, Burton M, Campbell M, Chalkidou K, Chalmers I, de Leval M, Deeks J, Grant A, Gray M, Greenhalgh R, Jenicek M, Kehoe S, Lilford R, Littlejohns P, Loke Y, Madhock R, McPherson K, Rothwell P, Summerskill B, Taggart D, Tekkis P, Thompson M, Treasure T, Trohler U, Vandenbroucke J (2009) Evaluation and stages of surgical innovations. Lancet 374:1089–1096PubMedCrossRefGoogle Scholar
  49. 49.
    McGinn FP, Miles AJ, Uglow M, Ozmen M, Terzi C, Humby M (1995) Randomized trial of laparoscopic cholecystectomy and mini-cholecystectomy. Br J Surg 82:1374–1377PubMedCrossRefGoogle Scholar
  50. 50.
    Ros A, Gustafsson L, Krook H, Nordgren CE, Thorell A, Wallin G, Nilsson E (2001) Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy: a prospective, randomized, single-blind study. Ann Surg 234:741–749PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Sandra van Brunschot
    • 1
    • 6
    Email author
  • Paul Fockens
    • 2
  • Olaf J. Bakker
    • 4
  • Marc G. Besselink
    • 3
  • Rogier P. Voermans
    • 2
  • Jan-Werner Poley
    • 5
  • Hein G. Gooszen
    • 1
  • Marco Bruno
    • 5
  • Hjalmar C. van Santvoort
    • 4
  1. 1.Department of OR/Clinical Surgical ResearchRadboud University Nijmegen Medical CenterNijmegenThe Netherlands
  2. 2.Department of GastroenterologyAcademic Medical Center and HepatologyAmsterdamThe Netherlands
  3. 3.Department of SurgeryAcademic Medical CenterAmsterdamThe Netherlands
  4. 4.Department of SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
  5. 5.Department of GastroenterologyErasmus MC, University Medical Center and HepatologyRotterdamThe Netherlands
  6. 6.Department of Gastroenterology and HepatologyAcademic Medical CenterAmsterdamThe Netherlands

Personalised recommendations