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Table 1 Main studies assessing minimally invasive techniques for severe necrotizing pancreatitis

From: Combined totally mini-invasive approach in necrotizing pancreatitis: a case report and systematic literature review

Study Design Number of cases Outcomes Limitations
van Santvoort et al. [7] Open necrosectomy vs. PD ± VARD, randomized controlled trial 88 patients (45 open necrosectomy vs. 43 PD ± VARD) Major complications occurred in 69% of open necrosectomy patients vs. 40% of PD ± VARD patients (p = 0.006); open necrosectomy was associated with more incisional hernias (p = 0.03) and new-onset diabetes (p = 0.02). Mortality was not different. Trial not designed to assess differences in mortality.
Bakker et al. [22] ETN vs. VARD or open necrosectomy, randomized controlled trial 20 patients (10 ETN vs. 10 VARD/open necrosectomy) ETN reduced both the proinflammatory response (p < 0.004) and major complications, multiple organ failure or death (p = 0.03) Small number of patients
Bausch et al. [23] VARD vs. ETN vs. open necrosectomy, retrospective study 32 patients (14 VARD vs. 18 ETN vs. 30 open necrosectomy) Open necrosectomy had higher overall mortality (p < 0.05), ongoing sepsis rates and bleedings; ETN was complicated by gastric perforation in 28% of cases requiring immediate laparotomy Small number of patients, retrospective study.
van Brunschot et al. [24] Endoscopic transgastric drainage ± ETN vs. PD ± VARD, randomized controlled trial 98 patients End-points are rates of major complications, need for re-interventions, quality of life, and cost-analysis between endoscopic step-up approach and surgical step-up approach. Results are still awaited. Results still awaited
Kumar et al. [19] ETN vs. PD ± open necrosectomy, matched cohort study 24 patients (12 ETN vs. 12 PD ± open necrosectomy) ETN was superior in clinical remission rate (p < 0.01) and reduced major complications, length of stay, and post-operative health care utilization (p < 0.01). Small number of patients.
Rasch et al. [25] Open necrosectomy vs. endoscopic transgastric drainage ± ETN ± PD, retrospective multicenter study 220 patients (30 open necrosectomy vs. 190 step-up approach) Lower complication rate (44.7 vs. 73.3%, p < 0.001), lower mortality (10.5 vs. 33.3%, p = 0.002), and lower incidence of diabetes (4.7 vs. 33.3%, p < 0.001) was demonstrated with step-up approach compared to open necrosectomy; 18.9% of step-up approach patients required open necrosectomy. Retrospective study
Carter et al.[10] Open necrosectomy + percutaneous necrosectomy vs. upfront percutaneous necrosectomy, case series 14 patients (4 open necrosectomy vs. 10 percutaneous necrosectomy) Upfront percutaneous necrosectomy by sinus tract endoscopy had 20% mortality vs. 0% with open necrosectomy, but only 40% of patients required ICU (vs. 100%). Retrospective case series, small number of patients
Gardner et al. [18] Endoscopic transgastric drainage vs. ETN, retrospective study 45 patients (25 ETN vs. 20 endoscopic transgastric drainage) Walled-off pancreatic necrosis successfully resolved in 88% of patients treated with ETN vs. 45% with endoscopic drainage (p < 0.01). Retrospective study, referral center bias
Raraty et al. [12] Open necrosectomy vs. VARD, retrospective study 189 patients (52 open necrosectomy vs. 137 VARD) Organ failure in 31% of patients treated by VARD vs. 56% with open necrosectomy (p < 0.0001); 43 vs. 77% respectively required ICU support. Mortality rate was 19% with VARD vs. 38% with open necrosectomy (p = 0.009). Retrospective study, referral center bias
Guo et al. [14] Open necrosectomy vs. retroperitoneal necrosectomy, retrospective study 412 patients (108 retroperitoneal necrosectomy vs. 304 open necrosectomy) Mortality rate was 8.3% with retroperitoneal necrosectomy vs. 20.4% with open necrosectomy (p = 0.004); complications rate and mean ICU stay were significantly lower. Retrospective study
Tan et al. [20] Open necrosectomy vs. ETN, multicentric retrospective study 32 patients (21 open necrosectomy vs. 11 ETN) Acute complications rate was 86% in open necrosectomy vs. 27% with ETN (p = 0.002), ICU stay and hospitalization were significantly reduced with ETN. Clinical severity scores were unbalanced between groups, retrospective study, small number of patients
Bang et al. [26] Endoscopic transgastric drainage ± ETN vs. “algorithmic approach” including endoscopic drainage, ETN, PD, percutaneous necrosectomy, open necrosectomy, observational study 100 patients (47 endoscopic transgastric drainage ± ETN vs. 53 “algorithmic approach”) Treatment success rate equal to 91% with “algorithmic approach” vs. 60% with endoscopic drainage ± ETN (p < 0.001). Observational study without randomization, unbalanced gender and race between groups
van Santvoort et al. [11] Open necrosectomy vs. VARD, case-matched retrospective study 30 patients (15 open necrosectomy vs. 15 VARD) Post-operative multiple organ failure occurred in 2 patients in VARD group vs. 10 patients treated by open necrosectomy (p = 0.0008). Complications and mortality rates were equal between groups. Retrospective study, small number of patients
Senthil Kumar et al. [15] Open necrosectomy vs. VARD, case-matched retrospective study 30 patients (15 open necrosectomy vs. 15 VARD) Post-operative complications in 26.6% of patients treated by VARD vs. 53.3% of patients treated by open necrosectomy (p = 0.248). Re-interventions, ICU stay, and hospitalization were similar. Retrospective study, small number of patients
Pupelis et al. [16] Open necrosectomy vs. ultrasound-focused necrosectomy, prospective study 58 patients (36 necrosectomy vs. 22 focused necrosectomy) Resolution of sepsis was earlier with focused necrosectomy; ICU stay longer with open necrosectomy (p = 0.024). Mini-invasive transgastric or percutaneous techniques not considered.
Tu et al. [13] Open necrosectomy vs. VARD, retrospective study 50 patients (32 open necrosectomy vs. 18 VARD) VARD was associated with shorter operative time (130 vs. 148 min, p = 0.007) and shorter hospitalization (40.8 vs. 55.9 days, p = 0.053) compared to open necrosectomy. Fewer complications with VARD (43.8 vs. 27.8%). Retrospective study
Gluck et al. [17] Endoscopic transgastric drainage + PD vs. PD only, retrospective study 95 patients (49 endoscopic drainage + PD vs. 46 PD only) Endoscopic drainage + PD significantly reduced hospitalization, CT scans, and ERCPs (p < 0.05) compared to PD only. Retrospective study
Woo et al. [21] Endoscopic transgastric drainage or ETN vs. open necrosectomy vs. PD 30 patients (12 endoscopic treatment vs. 8 PD vs. 10 open necrosectomy) Mean hospitalization time was 62 days with endoscopic treatment vs. 101 days with PD and 91 days with open necrosectomy (p = 0.046). Pancreatic fistula and new-onsetdiabetes were more frequent with open necrosectomy (p = 0.04, p = 0.012). Retrospective study, small number of patients
  1. PD, percutaneous drainage, ETN endoscopic transgastric necrosectomy, VARD video-assisted retroperitoneal debridement