Is necrosectomy obsolete for infected necrotizing pancreatitis? Is a paradigm shift needed?

Table 1 Results of nonsurgical or conservative treatment for necrotizing pancreatitis published mainly after 2000

Ref.	Year	Cases(n)	Type(Intend)	Morbidity(%)	Reoperationrate (%)	Mortality(%)	Remark
Sterile
Bradley[1]	1991	40	Nonsurgical			10.0
Uomo et al[61]	1996	146	Nonsurgical			9.5	1984-1993
Baril et al[20]	2000	26	Antibiotics		0	7.0	1993-1997
Büchler et al[62]	2000	56	Conservative			1.8	Two false negatives excluded
Zerem et al[41]	2009	20	Conservative		15.0	0.0	Randomized controlled study
Garg et al[54]	2010	137	Conservative			15.3	1997-2008
van Santvoort et al[18]	2011	386	Conservative			7.3	21 Dutch hospitals
Babu et al[46]	2013	14	Conservative			7.0	Step-up; one INP
Infected
Dubner et al[8]	1996	3	Antibiotics	0	0	0.0	Unstable or refused surgery
Baril et al[20]	2000	6	Antibiotics		0	33.0	1993-1997
Runzi et al[63]	2005	16	Antibiotics	62		12.5
Lee et al[19]	20071	8	Antibiotics	0	0	0.0
Garg et al[54]	20101	71	Conservative or PCD			25.4	1997-2008
van Santvoort et al[18]	2011	11	Antibiotics	0	0	0.0	21 Dutch hospitals
Sterile + infected
Büchler et al[62]	2000	58	Conservative			5.0	Two false negatives
Garg et al[54]	20101	208	Medical			18.8	1997-2008

¹Non-randomized controlled study. INP: Infected necrotizing pancreatitis; PCD: Percutaneous drainage.

Table 2 Results of surgical necrosectomy for necrotizing pancreatitis published mainly after 2000

Ref.	Year	Cases(n)	Type (Intend)	PF (%)	Morbidity(%)	Reoperation rate (%) or n/patient	Mortality(%)	Remark
Sterile
Baril et al[20]	2000	1	Open	0.0	0.0	0.0	0.0	1993-1997
Büchler et al[62]	2000	1	Closed+irrigation	?		?	100.0
Rau et al[64]	2005	142	Closed+irrigation	23.0	61.0	43.0	23.0	1992-2001
Howard et al[21]	2007	23	Planned re-lap		78.0	30.0	9.0	Symptomatic
Garg et al[54]	2010	9	Closed+irrigation	> 30.0			55.5	1997-2008
Infected
Baril et al[20]	2000	11	Open	NA	91.0	45.5	9.0	1993-1997
Büchler et al[62]	2000	27	Closed+irrigation	29.0		22.0	18.5	two un-OP excluded
Rau et al[64]	2005	140	Closed+irrigation	30.0	78.0	27.0	27.0	1992-2001
Howard et al[21]	2007	66	Surgery		86.0	33.0	15.0
Garg et al[54]	2010	36	Closed+irrigation		63.0		63.9	1997-2008
van Santvoort et al[15]	2010	45	Closed+irrigation	38.0	69.0	31.0	16.0	RCT; one operation, 42%; 33% need PCD
		24	VARD		65.0		17.0
van Santvoort et al[18]	2011	78	VARD/TEN/OP		64.0		18.0	21 Dutch hospitals
Babu et al[46]	2013	27	Closed+irrigation	22.2	51.9	22.2	40.7	Step-up
Sterile + infected
Smadja and Bismuth[11]	1986	12	Surgery, early				100.0
		15	Surgery, late				27.0
		11	Surgery, elective				0.0
Connor et al[39]	2005	47	Closed+irrigation		95.0		39.0	81% infected
Olakowski et al[65]	2006	144	Open packing		43.0	3-8/patient	21.0	83% infected
Nieuwenhuijs et al[66]	2003	38	Open packing	21.0	89.0	3-70/patient	47.0
		21	Closed+irrigation	14.0	44.0	0-3/patient	33.0
Reddy et al[40]	2006	118	Closed+irrigation	36.0	58.0	22.9	38.1	65.3% infected
Howard et al[21]	2007	102	Planned re-lap
	(1993-2001)	59		49.0	89.0	67.0	18.0	76% infected
	(2002-2005)	43		60.0	72.0	68.0	4.0	72% infected
Rodriguez et al[67]	2008	167	Closed packing	50.0		11.0	11.0	72% infected
Garg et al[54]	2010	45	Closed+irrigation				48.9	1997-2008
Babu et al[68]	2010	28	PCD + surgery				22.0	2000-2008
Doctor et al[22]	2011	61	Open + laproscopy (re-OP 8%)	50.8			9.8	1998-2009; 83.6% INP
Bausch et al[50]	2012	30	Closed+irrigation	16.7	90.0	73.3	63.3	83.3% infected
Madenci et al[23]	2014	68	Closed packing	74.2	> 74.2	14.7	8.8	2006-2009; 63% infected
Wormer et al[24]	2014	1783	Surgical debridement				22.0	1998-2010; nationwide

INP: Infected necrotizing pancreatitis; OP: Operation; PCD: Percutaneous drainage; PF: Pancreatic fistula; RCT: Randomized control study; Re-lap: Re-laparotomy; TEN: Transluminal endoscopic necrosectomy; un-OP: Not operated on; VARD: Video assisted retroperitoneal debridement.

Table 3 Results of minimal invasive necrosectomy for walled-off necrotizing pancreatitis published after 2000

Ref.	Year	Cases(n)	Type(Intend)	Sessions1	Completionrate (%)	Morbidity(%)	Reoperationrate (%)	Mortality(%)	Remark
Infected
Raczynski et al[25]	2006	2	TEND + irrigation	3	100.0	0.0	0.0	0.0	2 PEG
									(1st report?)
Escourrou et al[26]	2008	13	TEND + irrigation	1-3	100.0	46.0	0.0	0.0	+ PCD × 2
Bala et al[27]	2009	8	Lt RPD + N+ irrigation	3-17	87.5	25.0		12.5	Stepped
Antillon et al[28]	2009	1	TEN + stent		100.0	0.0	0.0	0.0	Transgastrostomy; Foley irrigation
Will et al[29]	2012	18	TEN ± PCD	3-8	100.0	16.6	0.0	0.0	One unrelated death
Bakker et al[30]	2012	10	TEND	2-6	100.0	20.0	0.0	10.0	RCT; 10% PF
		10	VARD/Lap	1-2	40.0	80.0	60.0	40.0	70% PF
Castellanos et al[31]	2013	32	VARD	1.0	100.0	9.3	0.0	15.6
Sarkaria et al[32]	2014	17	TEN + Stent ± PEG-J + irrigation	5.3	88.0	5.9	11.8	0.0	8 PEG-J
Sterile + infected
Connor et al[39]	2005	47	Lt. RPD + N	1-9		92.0		19.0	81% INP
		(NS)
Voermans et al[33]	2007	25	TEND + irrigation	NA	92.0	40.0	4.0	0.0	76% NP
Papachristou et al[34]	2007	53	TEND ± PCD ± PEG + irrigation	3	81.0	49.0	22.6	6.0	49% INP
Seifert et al[35]	2009	93	TEND	6	80.0	26.0	11.8	7.5	1999-2005
		(NS)
Raraty et al[36]	2010	137	VARD			75.0		19.0	64% INP
		(NS)
van Santvoort et al[15]	2010	43	Lt. RPD + N (Step-up)	1-7	35.0	40.0	60.0	19.0	RCT
		(NS)
Gardner et al[37]	2011	104	TEND	1-14	91.0	14.0	2.0	2.0	39% INP
Bausch et al[50]	2012	30	PCD + N		57.0	43.0	21.0	21.0	93% INP
		18	TEND		50.0	44.0	28.0	6.0	72% INP
Ross et al[10]	2014	117	TEND + PCD	NA	100.0	4.2	0.0	3.4	Dual modality
van Brunschot et al[38]	2014	455	TEN ± PCD	4 (1-23)	81.0	36.0	10.0	6.0	Systematic review; 57% INP
		(NS)

¹Values are mean or range. INP: Infected necrotizing pancreatitis; Lap: Laparotomy; N: Necrosectomy; NA: Not available; NS: Walled-off necrosis was not specified; PF: Pancreatic fistula; PCD: Percutaneous drainage; PEG-J: Percutaneous endoscopic gastrostomy-jejunal arm; RCT: Randomized control study; RPD: Retroperitonium percutaneous endoscopic gastrostomy; TEN: Transluminal endoscopic necrosectomy; TEND: Transluminal endoscopic necrosectomy with drainage; VARD: Video assisted retroperitoneal debridement; WON: Walled-off necrosis.

Table 4 Results of drainage without minimal invasive necrosectomy for necrotizing pancreatitis published mainly after 2000

Ref.	Year	Cases(n)	Type(Intend)	Sessions1	Success rate(%)	Morbidity(%)	Reoperationrate (%)	Mortality(%)	Remark
Sterile
Baril et al[20]	2000	13	PCD		92.3		7.7	0.0
Zerem et al[41]	2009	20	Conservative	1.5			15.0	0.0	RCT
		20	PCD	1.4	85.0		15.0	5.0
Infected
Freeny et al[52]	1998	34	PCD	3.3	47.0	26.0	53.0	12.0
Baril et al[20]	2000	25	PCD	1.4	76.0	8.0	18.0	8.0
Baron et al[44]	2002	38	TED + irrigation	2.0 (1-6)	79.0	NA	18.0	5.0
Lee et al[19]	2007	18 WON	PCD + irrigation		83.3	11.0	16.7	5.6	Non-RCT; 32% PF
		5	TED		80.0		20.0	0.0	6% PF
Bruennler et al[42]	2008	80	PCD	(1-14)	43.0	29.0	25.0	34.0	1999-2004; 10 + PCN
Mortelé et al[43]	2009	35	PCD	3.3	49.0	11.0	37.0	17.0
van Santvoort et al[18]	2011	130	PCD	NA	35.0	42.0	58.0	20.0	21 Dutch hospitals
Mukai et al[45]	2014	5 WON	SGTMD		100.0	0.0	0.0	0.0
Sterile + infected
Traverso et al[17]	2005	73	PCD	NA	79.0			11.0
Chang et al[9]	2006	19 WON	MIS Lt. flank	1.0	84.2	10.5	5.2	15.8	80% INP
Babu et al[46]	2013	29	PCD; step-up			20.0		6.8	86% INP
Varadarajulu et al[47]	2011	48 WON	TED		52.1	10.4	35.4	6.5
		12 WON	MTGT		91.7	0.0	0.0	0.0

¹Values are mean or range. INP: Infected necrotizing pancreatitis; MIS: Minimal invasive surgery; MTGT: Multiple transluminal gateway technique; NA: Not available; PCD: Percutaneous drainage; PCN: Percutaneous necrosectomy; PF: Pancreatic fistula; RCT: Randomized control study; SGTMD: Single transluminal gateway transcystic multiple drainage; TED: Transluminal endoscopic drainage; WON: Walled-off necrosis.