Objective Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking. Design We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%). Results Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005). Conclusion In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.

中文翻译：

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微创和内窥镜与开放性坏死性胰腺炎坏死性切除术：1980 名患者个体数据的汇总分析

目的与开放性坏死切除术相比，微创手术坏死切除术和内窥镜坏死切除术可能会改善坏死性胰腺炎的预后，尤其是危重患者。缺乏来自大型比较研究的证据。设计 我们将来自 15 个已发表和未发表的患者队列（51 家医院；8 个国家）的原始和新收集的数据结合起来，进行胰腺坏死切除术治疗坏死性胰腺炎。比较了接受开放性坏死切除术与微创手术或内窥镜坏死切除术的患者的死亡率。为了调整混杂因素并研究临床严重程度的影响修正，我们进行了两种类型的分析：逻辑多变量回归和倾向评分匹配，根据基线预测的死亡风险进行分层（低：<5%；中：≥5% 至 <15%；高：≥15% 至 <35%；并且非常高：≥35%）。结果 1980例坏死性胰腺炎患者中，1167例行开放性坏死切除术，813例行微创手术（n=467）或内镜（n=346）坏死切除术。微创手术坏死切除术（OR，0.53；95% CI 0.34 至 0.84；p=0.006）和内窥镜坏死切除术（OR，0.20；95% CI 0.06 至 0.63；p=0.006）的死亡风险较低。在将倾向评分与风险分层匹配后，在极高风险组中，微创手术坏死切除术的死亡风险仍然低于开放式坏死切除术（42/111 vs 59/111；风险比，0.70；95% CI 0.52 至 0.95） ；p=0.02）。在高危组中，内窥镜坏死切除术的死亡风险低于开放式坏死切除术（3/40 对 12/40；风险比，0.27；95% CI 0.08 至 0。88; p=0.03）和极高风险组（12/57 vs 28/57；风险比，0.43；95% CI 0.24 至 0.77；p=0.005）。结论 在坏死性胰腺炎的高危患者中，微创手术和内镜下坏死切除术与开放式坏死切除术相比死亡率降低。