Percutaneous endoscopic necrosectomy (PEN) for treatment of necrotizing pancreatitis: a systematic review and meta-analysis

Abstract

Background and study aims Endoscopic necrosectomy is limited by the proximity of necrosis to the gastrointestinal tract. Percutaneous endoscopic necrosectomy (PEN) is a minimally invasive endoscopic method of percutaneous debridement. Studies regarding its efficacy and safety are lacking. The purpose of this study was to assess the efficacy and safety of PEN in necrotizing pancreatitis.

Methods Pubmed, Ovid, Cochrane, Scopus and Web of Science Database were searched from inception through February 2021. Dual extraction and quality assessment of studies using Cochrane risk of bias tool were performed independently by two authors. The primary outcome was defined as clinical success of PEN. Secondary outcomes included periprocedural morbidity, mortality, and long-term morbidity and mortality.

Results Sixteen observational studies including 282 subjects were analyzed. The average reported age of the participants was 50.3 years. Patients with reported gender included 39 % females and 61 % males. The success rate as defined by complete resolution of necrosis and removal of drainage catheters/stents was 82 % (95 % confidence interval 77–87). The mean size of pancreatic necrosis was 14.86 cm (5–54 cm). The periprocedural morbidity rate was 10 %, while there was no reported periprocedural mortality. The long-term morbidity rate was reported as 23 % and mortality at follow-up was 16 %.

Conclusions PEN is a novel method of endoscopic management of pancreatic necrosis. Based on our meta-analysis of retrospective studies, it represents a safe treatment modality with high rates of clinical success and low rates of perioperative morbidity and mortality. This study supports the use of PEN when conventional endoscopic therapy is not feasible.

Publikationsverlauf

Eingereicht: 27. Oktober 2021

Angenommen nach Revision: 10. August 2022

Artikel online veröffentlicht:
23. März 2023

• References

• 1 Houghton EJ, Vázquez AAG, Zeledón ME. et al. Necrotizing pancreatitis: description of videoscopic assisted retroperitoneal debridement (vard) technique with covered metallic stent. Arq Bras Cir Dig 2018; 31: e1379
• 2 Arvanitakis M, Dumonceau JM, Albert J. et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy 2018; 50: 524-546
• 3 Bang JY, Holt BA, Hawes RH. et al. Outcomes after implementing a tailored endoscopic step-up approach to walled-off necrosis in acute pancreatitis. Br J Surg 2014; 101: 1729-1738
• 4 da Costa DW, Boerma D, van Santvoort HC. et al. Staged multidisciplinary step-up management for necrotizing pancreatitis. Br J Surg 2014; 101: e65-79
• 5 Trikudanathan G. Percutaneous endoscopic necrosectomy (PEN): Is the PEN mightier yhan the VARD?. Dig Dis Sci 2020; 65: 339-341
• 6 Thompson D, Bolourani S, Giangola M. Surgical management of necrotizing pancreatitis. Recent advances in pancreatitis. IntechOpen 2021;
• 7 Trikudanathan G, Attam R, Arain MA. et al. Endoscopic interventions for necrotizing pancreatitis. Am J Gastroenterol 2014; 109: 969-981 quiz 982
• 8 van Santvoort HC, Bakker OJ, Bollen TL. et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 2011; 141: 1254-1263
• 9 van Brunschot S, van Grinsven J, Voermans RP. et al. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol 2013; 13: 161
• 10 van Grinsven J, van Santvoort HC, Boermeester MA. et al. Timing of catheter drainage in infected necrotizing pancreatitis. Nat Rev Gastroenterol Hepatol 2016; 13: 306-312
• 11 Wroński M, Cebulski W, Karkocha D. et al. Ultrasound-guided percutaneous drainage of infected pancreatic necrosis. Surg Endosc 2013; 27: 2841-2848
• 12 van Baal MC, van Santvoort HC, Bollen TL. et al. Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg 2011; 98: 18-27
• 13 Nemoto Y, Attam R, Arain MA. et al. Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: Outcomes in a large cohort of patients. Pancreatology 2017; 17: 663-668
• 14 Gluck M, Ross A, Irani S. et al. Dual modality drainage for symptomatic walled-off pancreatic necrosis reduces length of hospitalization, radiological procedures, and number of endoscopies compared to standard percutaneous drainage. J Gastrointest Surg 2012; 16: 248-256 discussion 256-257
• 15 Carter CR, McKay CJ, Imrie C. Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience. Ann Surg 2000; 232: 175-180
• 16 Trikudanathan G, Wolbrink DRJ, van Santvoort HC. et al. Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach. Gastroenterology 2019; 156: 1994-2007.e3
• 17 Cumpston M, Li T, Page MJ. et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev 2019; 10: ED000142
• 18 Moher D, Liberati A, Tetzlaff J. et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009; 62: 1006-1012
• 19 Faber T, Ravaud P, Riveros C. et al. Meta-analyses including non-randomized studies of therapeutic interventions: a methodological review. BMC Med Res Methodol 2015; 16: 35
• 20 Trikudanathan G, Hashmi H, Dirweesh A. et al. Rendezvous transgastric and percutaneous sinus tract endoscopy (STE) for debridement of necrotic collections with deep retroperitoneal extension: a case series (with video): Meeting presentations: Digestive Disease Week 2018. Endosc Int Open 2020; 8: E668-E672
• 21 Moyer MT, Walsh LT, Manzo CE. et al. Percutaneous debridement and washout of walled-off abdominal abscess and necrosis by the use of flexible endoscopy: an attractive clinical option when transluminal approaches are unsafe or not possible. VideoGIE 2019; 4: 389-393
• 22 Jain S, Padhan R, Bopanna S. et al. Percutaneous endoscopic step-up therapy is an effective minimally invasive approach for infected necrotizing pancreatitis. Dig Dis Sci 2019; 65: 615-622
• 23 Ke L, Mao W, Zhou J. et al. Stent-assisted percutaneous endoscopic necrosectomy for infected pancreatic necrosis: technical report and a pilot study. World J Surg 2019; 43: 1121-1128
• 24 Thorsen A, Borch AM, Novovic S. et al. Endoscopic necrosectomy through percutaneous self-expanding metal stents may be a promising additive in treatment of necrotizing pancreatitis. Digest Dis Sci 2018; 63: 2456-2465
• 25 Tringali A, Vadalà di Prampero SF. et al. Endoscopic necrosectomy of walled-off pancreatic necrosis by large-bore percutaneus metal stent: a new opportunity?. Endosc Int Open 2018; 6: E274-E278
• 26 Goenka MK, Goenka U, Mujoo MY. et al. Pancreatic necrosectomy through sinus tract endoscopy. Clin Endosc 2018; 51: 279-284
• 27 Liu P, Song J, Ke HJ. et al. Double-catheter lavage combined with percutaneous flexible endoscopic debridement for infected pancreatic necrosis failed to percutaneous catheter drainage. BMC Gastroenterol 2017; 17: 155
• 28 Saumoy M, Kumta NA, Tyberg A. et al. Transcutaneous Endoscopic Necrosectomy for Walled-off Pancreatic Necrosis in the Paracolic Gutter. J Clin Gastroenterol 2018; 52: 458-463
• 29 Jürgensen C, Brückner S, Reichel S. et al. Flexible percutaneous endoscopic retroperitoneal necrosectomy as rescue therapy for pancreatic necroses beyond the reach of endoscopic ultrasonography: A case series. Dig Endosc 2017; 29: 377-382
• 30 Dhingra R, Srivastava S, Behra S. et al. Single or multiport percutaneous endoscopic necrosectomy performed with the patient under conscious sedation is a safe and effective treatment for infected pancreatic necrosis (with video). Gastrointest Endosc 2015; 81: 351-359
• 31 Castellanos G, Piñero A, Doig LA. et al. Management of infected pancreatic necrosis using retroperitoneal necrosectomy with flexible endoscope: 10 years of experience. Surg Endosc 2013; 27: 443-453
• 32 Tang LJ, Wang T, Cui JF. et al. Percutaneous catheter drainage in combination with choledochoscope-guided debridement in treatment of peripancreatic infection. World J Gastroenterol 2010; 16: 513-517
• 33 Mui LM, Wong SKH, Ng EKW. et al. Combined sinus tract endoscopy and endoscopic retrograde cholangiopancreatography in management of pancreatic necrosis and abscess. Surg Endosc 2005; 19: 393-397
• 34 van Brunschot S, van Grinsven J, van Santvoort HC. et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391: 51-58
• 35 Isayama H, Nakai Y, Rerknimitr R. et al. Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment. J Gastroenterol Hepatol 2016; 31: 1546-1554
• 36 Werge M, Novovic S, Schmidt PN. et al. Infection increases mortality in necrotizing pancreatitis: A systematic review and meta-analysis. Pancreatology 2015; 16: 698-707
• 37 Boumitri C, Brown E, Kahaleh M. Necrotizing pancreatitis: current management and therapies. Clin Endosc 2017; 50: 357
• 38 Trikudanathan G, Arain M, Attam R. et al. Interventions for necrotizing pancreatitis: an overview of current approaches. Expert Rev Gastroenterol Hepatol 2013; 7: 463-475
• 39 Bugiantella W, Rondelli F, Boni M. et al. Necrotizing pancreatitis: A review of the interventions. Int J Surg 2015; 28: S163-S171
• 40 Feng L, Guo J, Wang S. et al. Endoscopic transmural drainage and necrosectomy in acute necrotizing pancreatitis: a review. J Transl Int Med 2021; 9: 168-176