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Three Part Question

In an [adult with acute severe necrotising pancreatitis] does [Step up surgical intervention better than early surgical necrosetomies/] in [ improving survival and better outcome]

Clinical Scenario

A 45 year old male came to A&E with sever upper abdominal pain, and upon examination there is signs pf peritonism and elevated serum amylase more than 4 folds in addition to elevated CRP, WBC and fever.Within two days, he developed signs of acute severe necrotisig pancreatitis with Cullin and Turner signs and AKI for that we kept him on conservative treatment for more than 10 days

Search Strategy

Pubmed interface on the world wide web.
[ exp adult or exp severe acute necrotising pancreatitisor necrotising pancreatitis or acute severe pancreatitis or acute pancreatitis]and [exp Step up surgical intervention or minimal surgical intervention or conservative managment or early surgical necrositomies or necrositomies] and [ improving survival or better outcome or decreasing mortality or mortality or morbidity] Limit to 2014-2021, English Language, Systematic review, Meta-analysis, Randomised controled trials and

Search Outcome

901 studies are allocated from which 889 were irrelevant and excluded in first phase.Then, the remainig 12 studies were reviewed in the second phase and only 6 were relevant to our BET

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Haney CM, Kowalewski KF, Schmidt MW, et al 2020 Feb 28 Germany	Infected necrotizing pancreatitis	a systematic review and meta-analysis of randomized controlled trials	The main outcomes were mortality and new onset multiple organ failure	No difference in mortality, patients in the endoscopic group had statistically significant lower odds of experiencing new onset multiple organ failure (odds ratio (OR) confidence interval [CI] 0.31 [0.10, 0.98])	The quality of evidence was moderate for most outcomes due to umber of less than 200 radomized patients
Bang JY, Arnoletti JP, Holt BA,et al. 2018 Nov 16. United States of America	Patients With Necrotizing Pancreatitis	a single-center, randomized trial of 66 patients with confirmed or suspected infected necrotizing pancreatitis who required intervention from May 12, 2014, through March 24, 2017	The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months	The primary endpoint occurred in 11.8% of patients who received the endoscopic procedure and 40.6% of patients who received the minimally invasive surgery (risk ratio 0.29; 95% confidence interval 0.11–0.80; P ¼ .007). Although there was no significant difference in mortality (endoscopy 8.8% vs surgery 6.3%; P ¼ .999),	This study was conducted at a single, tertiary care referral center.
Yong Hu , Chunyan Li , Xin Zhao and Yunfeng Cu 2018 China	infected necrotizing pancreatitis	a systematic review and meta-analysis	pancreatic fistulas,the length of hospital stay, mortalityrate , multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, recurrence of pseudocysts, and length of stay (LOS) in the Intensive Care Unit (ICU), endocrine insufficiency and exocrine insufficiency.	No marked differences were found in favor of the endoscopic approach in terms of pancreatic fistulas (OR = 0.10, 95% CI 0.04-0.30, p < 0.001) and the length of hospital stay (weighted mean difference [WMD] = -24.72, 95% CI = -33.87 to -15.57, p < 0.001)erms of mortality, multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, recurrence of pseudocysts, and length of stay (LOS) in the Intensive Care Unit (ICU), endocrine insufficiency and exocrine insufficiency.However,a statistically significant results were found in	The studies included in the meta-analysis were not all RCTS.In addition, all the included studies of the endoscopic approach were not completely similar
Zhang K, Zhu X, Hou C, Shi C, Miao Y, Li Q 2019 Oct 21 China	SAP Severe acute pancreatitis/SMAP severe moderate acute pancreatitis	a network meta-analysis	mortality and multiple organ dysfunction syndrome (MODS) rate	Both Early minimal invasive drainage and MID can significantly decrease the mortality and MODS rate compared to Conservative tratment andComparison of mortality (34/453 in MID and 29/136 in OSD with 50/342 in CST) and MODS rate (15/196 in MID and 33/91 in Open Surgical Drainage with 17/119 in CST)	It is not an interventional study in which improvement could be made.
Yun-Bing Wang, Xiao-Li Yang, Long Chen,et al. 2018 Aug China	infected necrotizing pancreatitis	A meta-analysis	postoperative complication rate , postoperative mortality , higher technical success rate, similar surgical reintervention rate , shorter operative time , and shorter hospital stay	retroperitoneal group had a lower postoperative complication rate [risk ratio (RR) = 0.575, 95% confidence interval (CI) = 0.459 to 0.719, P < 0.001], lower postoperative mortality (RR = 0.525, 95% CI = 0.430 to 0.642, P < 0.001)	thestatistical heterogeneity, which may have biased the results of this meta-analysis
Zhang ZH, Ding YX, Wu YD, Gao CC, Li F 2018 Nov 21 China	Infected pancreatitis necrosis	A meta-analysis	Bleeding, mortality , hospital duration, duration in intensive care unit (ICU) , pancreatic fistula , and organ failure	nly PCD is statistically significant in decreasing Bleeding (RR: 0.42, 95% CI: 0.25-0.70) i comparison to surgical intervention	retrospective researches in most studies included in it

Comment(s)

All studies included in this BET are systematic reviews and meta-analysis with at least moderate evidence of there results. Step up Minimal invasive therapy is superior to open surgical drainage in different aspects according to differet studies.However, MID is usually reduce the rate of multi-organ failure and morbidities associated with acute severe pancreatitis, it has no statistically significance on survival i most of the studies involved in this BET

Clinical Bottom Line

Minimal invasive therapy should be used in step up manner in treating acute severe necrotising pacreatitis aiming to reduce morbidity and improving outcome.

References

1. Haney CM, Kowalewski KF, Schmidt MW, Koschny R, Felinska EA, Kalkum E, Probst P, Diener MK, Müller-Stich BP, Hackert T, Nickel F. Endoscopic versus surgical treatment for infected necrotizing pancreatitis: a systematic review and meta- analysis of randomized controlled trials Surg Endosc. 2020 Jun;34(6):2429-2444. doi: 10.1007/s00464-020-07469-9. Epub 2020 Feb 28. PMID: 32112252; PMCID: PMC7214487. 2020,16
2. Bang JY, Arnoletti JP, Holt BA, Sutton B, Hasan MK, Navaneethan U, Feranec N, Wilcox CM, Tharian B, Hawes RH, Varadarajulu S An Endoscopic Transluminal Approach, Compared With Minimally Invasive Surgery, Reduces Complications and Costs for Patients With Necrotizing Pancreatitis Gastroenterology. 2019 Mar;156(4):1027-1040.e3. doi: 10.1053/j.gastro.2018.11.031. Epub 2018 Nov 16. PMID: 30452918. 2019
3. Yong Hu , Chunyan Li , Xin Zhao and Yunfeng Cu An endoscopic or minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis Rev Esp Enferm Dig . 2019 Jun;111(6):471-480. doi: 10.17235/reed.2019.5792/2018 2019
4. a network meta-analysis Minimally invasive drainage versus open surgical debridement in SAP/SMAP – a network meta-analysis BMC Gastroenterol. 2019; 19: 168. Published online 2019 Oct 21. doi: 10.1186/s12876-019-1078-x 2019; 19: 168
5. Yun-Bing Wang, Xiao-Li Yang, Long Chen, Zheng-Ju Chen, Chun-Mu Miao and Jin Xia Retroperitoneal versus open intraperitoneal necrosectomy in step-up therapy for infected necrotizing pancreatitis: A meta-analysis Int J Surg . 2018 Aug;56:83-93. doi: 10.1016/j.ijsu.2018.06.012. Epub 2018 Jun 12. 2018 Aug;56:83-93
6. Zhang ZH, Ding YX, Wu YD, Gao CC, Li F A meta-analysis and systematic review of percutaneous catheter drainage in treating infected pancreatitis necrosis Medicine (Baltimore) . 2018 Nov;97(47):e12999. doi: 10.1097/MD.0000000000012999. 2018 Nov;97(47)