Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic 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.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

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 141:1254–1263

  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 371:651–659

  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 6:6

  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 251:787–793

  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 247:294–299

  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 362:1491–1502

  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 579–580

  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 251:783–786

  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 232:619–626

  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 137:499–505

  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 11:43–49

  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 138:28–39

  13. 13.

    Tsiotos GG, Luque-de Leon E, Sarr MG (1998) Long-term outcome of necrotizing pancreatitis treated by necrosectomy. Br J Surg 85:1650–1653

  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 307:1053–1061

  15. 15.

    Seifert H, Wehrmann T, Schmitt T, Zeuzem S, Caspary WF (2000) Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 356:653–655

  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–e130

  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 128:586–590

  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 52:377–384

  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 73:712–716

  20. 20.

    Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH (1990) Acute pancreatitis: value of CT in establishing prognosis. Radiology 174:331–336

  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 183:1261–1265

  22. 22.

    Balthazar EJ, Ranson JH, Naidich DP, Megibow AJ, Caccavale R, Cooper MM (1985) Acute pancreatitis: prognostic value of CT. Radiology 156:767–772

  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 5:13

  24. 24.

    Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558

  25. 25.

    Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560

  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):3911–3920

  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–S134

  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 38:925–928

  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 26:364–369

  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 248:1074–1080

  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 69:1085–1094

  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 73:718–726

  33. 33.

    Papachristou GI, Takahashi N, Chahal P, Sarr MG, Baron TH (2007) Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg 245:943–951

  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 48:231–240

  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 8:271–276

  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 62:92–100

  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 58:1260–1266

  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 66:909–916

  39. 39.

    Gurusamy KS, Farouk M, Tweedie JH (2005) UK guidelines for the management of acute pancreatitis. Gut 54(Suppl 3):1–9

  40. 40.

    Forsmark CE, Baillie J (2007) AGA Institute technical review on acute pancreatitis. Gastroenterology 132:2022–2044

  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 132:2019–2021

  42. 42.

    Banks PA, Freeman ML (2006) Practice guidelines in acute pancreatitis. Am J Gastroenterol 101:2379–2400

  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 2:565–573

  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 29:102–107

  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 23:2770–2777

  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 1:121–130

  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 375:475–480

  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 374:1089–1096

  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 82:1374–1377

  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 234:741–749

Download references

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.

Author information

Correspondence to Sandra van Brunschot.

Additional information

For the Dutch Pancreatitis Study Group.

Appendix 1

Appendix 1

Extensive search terms used within the PubMed, Embase, and Cochrane Library

The PubMed search terms were ‘((endoscopic transluminal necrosectomy*) OR (endoscopic necrosectomy*) OR (endoscopic debridement*) OR (endoscopic drainage*) OR (transluminal drainage*) OR (transgastric necrosectomy*) OR (transgastric debridement*)) AND ((pancreatitis[Mesh]) OR (Pancreatitis [Text Word]) OR (pancreatic*) OR (pancreas*) OR (infected necrosis*) OR (OPN*))’.

The following strategy was used to search Embase: (pancreatitis/or pancreatic/or pancreas/or infected necrosis/or OPN.tw)) AND (endoscopic transluminal necrosectomy/or endoscopic necrosectomy/or endoscopic debridement/or endoscopic drainage/or transluminal drainage/or transgastric necrosectomy/or transgastric debridement.tw).

Search terms for the Cochrane Library were: ‘((pancreatitis*) OR (pancreatic*) OR (pancreas*) OR (infected necrosis*) OR (OPN*)) AND ((endoscopic transluminal necrosectomy*) OR (endoscopic necrosectomy*) OR (endoscopic debridement*) OR (endoscopic drainage*) OR (transluminal drainage*) OR (transgastric necrosectomy*) OR (transgastric debridement*)), restricted to title, abstract, keywords and the English language.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

van Brunschot, S., Fockens, P., Bakker, O.J. et al. Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review. Surg Endosc 28, 1425–1438 (2014). https://doi.org/10.1007/s00464-013-3382-9

Download citation

Keywords

  • Necrotising pancreatitis
  • Endoscopy
  • Intervention
  • Necrosectomy
  • Systematic