Systematic Review And Comparative Study Of Curative Effects Of Endoscopic And Surgical Necrosectomy In The Infected Pancreatic Necrosis

BackgroundIPN(Infected pancreatic necrosis)is a serious complication of severe acute pancreatitis,occurred in the onset of severe acute pancreatitis in 3 ~ 4 weeks later,often associated with sepsis,multiple organ failure,intra-abdominal bleeding,gastrointestinal fistula and other complications.It is second mortality peak of acute pa ncreatitis and the mortality rate is as high as 15% ~ 39%.Although ON(open necrosetomy)is a standard method for the treatment of IPN,which can completely remove the necrotic tissue and achieve the purpose of treatment,it is relatively larger injury for major organs of multiple systems(including respiratory system,circulatory system,etc.),the incidence of complications and mortality rate of up to 34-95% and 11-39%.With the continuous development of endoscopic diagnosis and treatment technology and change of minimally invasive concept,in recent years,many literatures have reported that endoscopic minimally invasive treatment of IPN,the preliminary results show that the incidence of complications and mortality compared with surgery has been improved.However,the current literatures mainly includes case series studies,and few case control studies,especially with fewer RCT,and fewer samples.The situation inevitably lead to a lower level of evidence in the literature on pancreatitis guidelines,furth er affected the practicability of the relevant guidelines.Therefore,the reference literature in the guidelines of pancreatitis is low level of evidence,further affect the related guide practicality.ObjectiveTo evaluate current status treatment of the EN and ON in the infected pancreatic necrosis,and to Compare the clinical curative effect of EN and ON,and to provide scientific evidence for EN of the IPN and further study of clues.Methods1.Select literatures of EN and(or)ON,the number of cases of 3 or more in the every literature,through electronically retrieve Pub Med,Medline,Embase,Springer,CBM,CNKI,Wan Fang database,etc.To perform systematic and comprehensive evaluation about EN and ON in the treatment of INP,included the incidence rate of complication,mortality rate,number of operation,hospitalization days,ICU days,cost of hospitalization,etc.2.To compare characteristics and clinical outcome of patients treated by the two techniques,a retrospective comparison of 34 patients treated by endoscopic necrosectomy in our endoscopy center(group E)with 34 patients treated in another two hospitals by surgical necrosectomy(group S).All of these patients were selected from June 2009 to June 2016.Result1.System review results:(1)Literature screening results: Finally,a total of 46 articles were included,of which there were a total of 7 case reports,and 35 case series studies,3 CCT,1 RCT.A total of 1244 patients were included in this study.The average sample size of this stud y was 28 cases(3-104).(2)Evaluation results of EN in the treatment of IPN:A total of 34 articles were included in this study,of which a prospective study was performed in 2 articles(5.88%),and a retrospective study of 32 articles(94.12%).A total of 23 articles were used to describe the mortality rate,and a total of 708 patients were included in the study.There were a total of 52 deaths,and the mortality rate is 11%(95% CI 9%-14%),through Meta analysis.A total of 34 articles described the complications,with an average incidence of 13.43%,including bleeding of 6.65%,organ failure of 0.42%,shock of 0.28%,pancreatic fistula of 0.28%,diabetes mellitus of 3.19,intestinal perforation of 10.80%,and so on.The transit rate from EN to ON was 16%(95%CI 15%-18%).(3)Evaluation results of ON in the treatment of IPN:A total of 8 articles were included in this study,of which a prospective study was performed in 2 articles(25%),and a retrospective study of 6 articles(75%).A total of 8 articles were used to describe the mortality rate,and a total of 273 patients were included in the study.There were a total of 44 deaths,and the mortality rate is 22%(95% CI 17%-28%),through Meta analysis.with an average mortality rate of 16.12%(0-39.02%).A total of 5 articles described the complications,with an average incidence of 74.55%,including bleeding of 11.61%,organ failure of 21.88%,pancreatic fistula of 23.21%,intestinal fistula of 8.93%,incisional hernia of 3.57%,incision infection and so on.(4)Evaluation results of EN vs.ON in the treatment of IPN:A total of 4 articles were included in this study,including 3 CCT and 1 RCT.A total of 87 patients were included in this study,including EN group 42 cases and ON group 45 cases.The re was no significant difference in the risk of death between the EN group and ON group(OR=0.61,95% CI 0.19-1.96),P = 0.4081,through Meta analysis.A total of 4 articles described the complications,including bleeding of 7.14%,organ failure of 11.90%,pancreatic fistula of 2.38%,intestinal perforation of 2.38%,diabetes mellitus of 7.14% in EN group,and bleeding of 8.89%,organ failure of 22.22%,pancreatic fistula of 42.22%,intestinal obstruction of 8.89%,intestinal perforation of 6.67%,incisional hernia 20%,diabetes mellitus of 22.22% in ON.2.Controlled clinical study results:The success rate of the two groups in the operation were 100%.Mortality rate occurred in 8.82 % of cases in the endoscopic group versus 41.18 % in the surgical group(P<0.01).Endoscopic and surgical group complications were 11.76% and 67.65%,respectively(P <0.01).Bleeding,organ failure and shock as main complications,endoscopic and surgical group were 2.94% and 61.76%,0% and 41.18%,2.94% and 47.06%,respectively(P < 0.01).The recurrence rate of the two groups were 8.82%.The number of operations,the length of hospital stay and the hospitalization cost were 2.62 times(1-10)and 1.06 times(1-2)(P < 0.01),83.5 days(7-175)and 54.2 days(2-154)(P<0.05),351800 yuan(28100-1476100)and 218400 yuan(33300-742700)(P< 0.01),respectively.Conclusion1.Current status of literatures:(1)The sample size of these studies is less,and the baseline data is different,and most of them are difficult to merge data.(2)Most of these studies is a single arm,lack of multi center and the design specification of high intensity of research.(3)Endoscopy is superior to surgery in initial impressions.2.Controlled clinical study: The complications and mortality of endoscopic necrosectomy was significantly lower than surgical necrosectomy.The number of operations,the length of hospital stay and the hospitalization cost of endoscopic necrosectomy was higher than surgical necrosectomy.