10 Transmural Pancreatic Necrosectomy: A Systematic Review and Meta-Analysis on Different Endoscopic Approaches

Abstract

INTRODUCTION: Acute pancreatitis is complicated by necrosis of the peripancreatic tissue in about 20% of patients. Over the past few decades, endoscopic necrosectomy (EN) is increasingly gaining traction as primary management. EN techniques are subject to rapid innovations, recently fully covered self-expanding metal stents (FCSEMS), bi-flanged metal stent (BFMS), plastic and lumen-apposing metal stents (LAMS) has taken the place of direct endoscopic necrosectomy (DEN). This study sought to determine the efficacy and safety of these approaches. METHODS: The MedLine, Embase, and Cochrane databases were systematically searched since inception till Jan 2019 and 4678 articles were retrieved. Only 59 articles deemed relevant and were analyzed using the Meta-disc. RESULTS: The weighted mean number of days in the hospital for BFMS was lowest (4.1) compared to plastic (32) and LAMS (60). The pooled proportion of successful symptoms resolution after DEN was 78.27% ± 28.15% (16.70%–94%), compared to 90 and 94% for plastic and BFMS and 100% for FCSEMS and LAMS. Radiological resolution after DEN was recorded to be 84.75%, increasing to 98%, 98.85% and 100% after plastic, FCSEMS and BFMS respectively. Overall mean complications rate was significantly high 30.46% ± (18.58%, 0–71%) in the DEN group, followed by plastic stenting 23.72% (P = 0.002). FCSEMS (16%) and BFMS (7.50%) had the lowest proportion of complications. The weighted mean recurrence of disease post-FCSEMS procedure was 23.25% and 14.75% after DEN while no recurrence occurred after BFMS. For pancreatic necrosis that did not resolve, 100% of the LAMS group, more than half of plastic and FCSEMS, and only 47% of BFMS patients had a repeat procedure. The weighted mean of mortality was highest but statistically non-significant in FCSEMS 8.62% followed by direct ETN 8.07% and BFMS patients 3.20%. CONCLUSION: EN is emerging as an increasingly popular technique, rapidly expanding the domain of therapeutic endoscopists. The highest rate of complications with DEN can be explained by the aggressive nature of procedure devoid of stentings such as puncturing the gastric or duodenal wall. Plastic, FCSEMS, and BFMS have lower procedure-related complications, and hospital stays due to small stent size and a targeted approach. The clinical and radiological resolution with these approaches were also better than DEN, but repeat procedure for stent removal or EN revision was often required. The mortality was not significantly different for different approaches.