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RESEARCH ARTICLE
ANNALS OF MEDICINE
2023, VOL. 55, NO. 2, 2276816
Endoscopic versus minimally invasive surgical approach for infected
necrotizing pancreatitis: a systematic review and meta-analysis of
randomized controlled trials
Penghao Tanga, Kamran Alib , Hayat Khizarb , Yuanzhi Nic, Zhiwen Chengc, Benfeng Xua, Zhiwen
Qina and Wu Zhangd
aGraduate School of Zhejiang, Chinese Medical University, Hangzhou, Zhejiang, China; bDepartment of Oncology, The Fourth Aliated
Hospital, International Institutes of Medicine, Zhejiang University School of Medicine, Zhejiang, China; cGraduate School of Zhejiang
University School of Medicine, Hangzhou, Zhejiang, China; dDepartment of Hepatobiliary Pancreatic Surgery, Shulan (Hangzhou)
Hospital Aliated to Zhejiang Shuren University, Shulan International Medical College, Zhejiang, China
ABSTRACT
Background/Aims: Acute pancreatitis is a common condition of the digestive system, but
sometimes it develops into severe cases. In about 10–20% of patients, necrosis of the pancreas
or its periphery occurs. Although most have aseptic necrosis, 30% of cases will develop infectious
necrotizing pancreatitis. Infected necrotizing pancreatitis (INP) requires a critical treatment
approach. Minimally invasive surgical approach (MIS) and endoscopy are the management
methods. This meta-analysis compares the outcomes of MIS and endoscopic treatments.
Methods: We searched a medical database until December 2022 to compare the results of
endoscopic and MIS procedures for INP. We selected eligible randomized controlled trials (RCTs)
that reported treatment complications for the meta-analysis.
Results: Five RCTs comparing a total of 284 patients were included in the meta-analysis. Among
them, 139 patients underwent MIS, while 145 underwent endoscopic procedures. The results
showed significant differences (p < 0.05) in the risk ratios (RRs) for major complications (RR: 0.69,
95% confidence interval (CI): 0.49–0.97), new onset of organ failure (RR: 0.29, 95% CI: 0.11–0.82),
surgical site infection (RR: 0.26, 95% CI: 0.07–0.92), fistula or perforation (RR: 0.27, 95% CI: 0.12–
0.64), and pancreatic fistula (RR: 0.14, 95% CI: 0.05–0.45). The hospital stay was significantly
shorter for the endoscopic group compared to the MIS group, with a mean difference of 6.74 days
(95% CI: −12.94 to −0.54). There were no significant differences (p > 0.05) in the RR for death,
bleeding, incisional hernia, percutaneous drainage, pancreatic endocrine deficiency, pancreatic
exocrine deficiency, or the need for enzyme use.
Conclusions: Endoscopic management of INP performs better compared to surgical treatment
due to its lower complication rate and higher patient life quality.
1. Introduction
Acute pancreatitis is a common gastrointestinal condi-
tion that often requires hospitalization. In approxi-
mately 10–20% of patients, necrosis of the pancreas or
peri-pancreas develops [1,2]. While most cases of
necrosis remain sterile, around 30% of patients develop
an accompanying infection. This infection can be iden-
tified by the presence of gas in the collection, positive
culture results from the necrotic aspirate, long-term
sepsis, or ongoing clinical deterioration [3–7]. Recent
studies have shown that minimally invasive surgery
(MIS) can effectively treat such conditions. Specifically,
laparoscopic cystogastrostomy with internal debride-
ment has been found to be superior to open surgical
necrosectomy with internal debridement performs bet-
ter than open surgical necrosectomy [8–12]. During
the endoscopic drainage procedure, an internal endo-
prosthesis is inserted endoscopically to facilitate
transluminal drainage. This technique can involve
endoscopic mechanical debridement as well as the
© 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
CONTACT Wu Zhang wu.zhang@shulan.com Shulan (Hangzhou) Hospital Aliated to Zhejiang Shuren University Shulan International Medical
College, No. 848 Dongxin Road, Hangzhou 310022, Zhejiang Province, P.R. China
https://doi.org/10.1080/07853890.2023.2276816
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the
Accepted Manuscript in a repository by the author(s) or with their consent.
ARTICLE HISTORY
Received 10 August 2023
Revised 17 September
2023
Accepted 9 October 2023
KEYWORDS
Infected necrotizing
pancreatitis; endoscopy;
minimally invasive
surgery; complications;
necrosectomy
2P. TANG ETAL.
use of percutaneous drainage catheters [13]. Based on
these findings, both endoscopic and minimally inva-
sive surgical approaches offer less invasive alternatives
to open surgical necrosectomy and have proven effec-
tive in treating infected necrotizing pancreatitis.
Randomized clinical trials have investigated these
treatments, with the endoscopic approach showing a
lower incidence of major adverse events [14–16]. The
positive outcomes can be attributed to reduced surgi-
cal anxiety and associated challenges, such as pancre-
atic fistulas, as well as the elimination of general
anaesthesia and exploratory surgical procedures. If
endoscopic transluminal drainage fails to significantly
improve the patient’s clinical condition, an endoscopic
necrosectomy can be considered as an alternative.
Alternatively, a step-up technique can be employed,
where drainage is performed initially.
Many published studies have small sample sizes,
making it challenging to draw definitive conclusions
[14,15]. Therefore, there is a pressing need for a
meta-analysis that incorporates updated information.
Meta-analysis is particularly valuable when evaluating
treatment effectiveness based on a large sample size,
which may not be feasible through individual analyses
of several trials producing negative results [14].
Previous meta-analyses have included only a small
number of studies and encompassed both randomized
controlled trials (RCTs) and observational studies
[17–19].
In this study, we conducted a meta-analysis specifi-
cally focused on RCTs to compare the surgical and
endoscopic treatments for infected necrotizing
pancreatitis.
2. Materials and methods
To accurately present this meta-analysis, we adhered
to the PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) guidelines for comprehen-
sive reporting of systematic reviews and meta-
analyses [20].
2.1. Search strategy
In our study, we conducted a comprehensive search
of medical databases, namely PubMed, Web of
Science, and the Cochrane Library, to identify rele-
vant articles pertaining to our research topic. Various
search terms and combinations, such as ‘endoscopic
drainage,’ ‘surgical drainage,’ ‘Minimally invasive sur-
gery,’ and ‘necrotizing pancreatitis,’ were utilized to
maximize the scope of our search. The search period
extended until December 2022, and we exclusively
focused on studies published in English that involved
human subjects.
To ensure a robust selection of studies, two authors
collaborated in the process of gathering articles that
were deemed significant for inclusion in our reference
list. Discrepancies or differences of opinion regarding
the final list were resolved through transparent and
thorough discussions.
2.2. Studies selection
To ensure the inclusion of relevant and reliable studies
in our meta-analysis, we employed rigorous criteria
during the study selection process. We established
both inclusion and exclusion criteria to ensure the
inclusion of high-quality studies that met our pre-
defined standards. By implementing these criteria, we
aimed to maintain the integrity and validity of our
meta-analysis results.
2.3. Inclusion criteria
1. Only full-text RCTs were included for evaluation.
2. Studies that involved patients diagnosed with
infected necrotizing pancreatitis were considered.
3. The studies compared the incidence of adverse
events and mortality between surgical drainage
and endoscopic drainage as therapeutic
interventions.
4. Only studies published in the English language
were included.
5. The studies included patients aged 18 years or
older.
2.4. Exclusion criteria
1. Non-randomized controlled trials, including
observational studies, case reports, abstracts,
reviews, or letters, were excluded.
2. Studies that did not directly compare the eec-
tiveness of surgical and endoscopic treatments
for necrotizing pancreatitis were not included.
3. Studies with only one treatment arm or missing
required results were excluded.
4. Studies not published English were excluded.
2.5. Data extraction
Following the predefined research selection criteria,
two authors independently performed data extraction.
The extracted information encompassed the study
ANNALS OF MEDICINE 3
names, study designs, patient demographics, disease
characteristics, specifics of endoscopic and surgical
interventions, as well as details pertaining to the pri-
mary outcome measures. These outcome measures
encompassed rates of adverse events, endocrine and
exocrine pancreatic insufficiency, and length of hospi-
tal stay. To ensure consistency, various coefficients
underwent a scaling process.
Each study included two distinct arms: an endo-
scopic arm and a surgical arm. In the event of any dis-
agreements regarding the extracted data, the first two
authors consulted with the third author to reach a
consensus and resolve discrepancies.
2.6. Outcomes and denitions
Our primary outcome was major complications, which
were defined as the sudden loss of function or failure
of one or more organs in the body, such as the heart,
lungs, or kidneys, leading to death or requiring inter-
vention. Secondary outcomes encompassed death or
mortality, specific components of major complications
(e.g. new onset of organ failure, bleeding), endocrine
pancreatic insufficiency, exocrine pancreatic insuffi-
ciency, fistula or perforation (including pancreatic fis-
tula), incisional hernia, additional percutaneous
drainage, surgical site infection, need for enzyme use,
length of hospital stay, and procedure time. Given the
specificity of these secondary outcomes, no further
definitions were provided.
2.7. Statistical analysis
The statistical analysis in our study was conducted
using Cochrane Review Manager Software, version
5.4.1. Risk ratios (RRs) and their corresponding 95%
confidence intervals (CIs) were calculated for each out-
come. The pooled RRs and CIs were determined using
the Mantel-Haenszel technique of the fixed effect
model. Mean differences were calculated using the
continuous inverse variance approach with a fixed
effect model.
To evaluate statistical heterogeneity, we employed
the Cochrane x2 test and assessed the I2 statistic. The
I2 statistic represents the proportion of total variation
across studies that is attributed to heterogeneity.
Values of 25–49% indicate low heterogeneity, 50–74%
indicate moderate heterogeneity, and values greater
than 75% indicate high heterogeneity [21]. To explore
the possibility of publication bias, a funnel plot was
utilized. Statistical significance was determined by a
p-value less than 0.05, indicating the data to be statis-
tically significant.
2.8. Risk of bias
To assess the risk of bias, we employed the Cochrane
Collaboration tools [22]. Ratings of ‘low’ indicated a
low risk of bias, ‘high’ indicated a high risk, and ‘some
concerns’ indicated that there was insufficient data to
determine the likelihood of bias. We comprehensively
evaluated various aspects including randomization, the
extent of missing data in the results, the timing of par-
ticipant identification or recruitment, outcome mea-
surement, the potential bias resulting from deviations
from intended interventions, and outcome selection.
2.9. Publication bias and study eect
To assess the presence of publication bias, we
employed a funnel plot based on the final results. This
graphical representation allowed us to visually exam-
ine the potential asymmetry in the distribution of
study outcomes.
Furthermore, a sensitivity analysis was conducted to
evaluate the impact of individual studies on the over-
all results. This analysis involved systematically exclud-
ing studies and observing the resulting changes in the
outcomes. Studies were excluded from the analysis if
their inclusion had a substantial influence on the final
results, thereby ensuring robustness and reliability in
our findings.
3. Results
3.1. Study selection
A total of 623 articles were initially identified through
medical databases and supplementary sources. After
removing duplicates and irrelevant publications based
on subject and title evaluation, 372 articles remained
for further assessment of eligibility. During this pro-
cess, abstracts, retrospective studies, single-arm stud-
ies, case reports, reviews, letters, animal studies, as
well as studies with incomplete or missing outcome
data were excluded.
As a result, a final selection of five studies met the
inclusion criteria for the meta-analysis. The flow chart
visually depicts the screening process and illustrates
the journey from the initial pool of articles to the five
articles considered in the final analysis (Figure 1
flow chart).
3.2. Studies characteristics
The selected randomized controlled trials investigating
the management of necrotizing pancreatitis involved a
4P. TANG ETAL.
total of 284 enrolled patients. Among these patients,
139 underwent minimally invasive surgical (MIS) drain-
age, while the remaining 145 individuals received
endoscopic drainage.
These trials were conducted in different countries,
including India [23,24], the United States of America
[15], and the Netherlands [14,16]. Detailed characteristics
of each study can be found in Tables 1–3. The aetiology
of necrotizing pancreatitis varied among the studies and
included factors such as alcohol consumption, gall-
stones, idiopathic causes, hypertriglyceridemia, post-ERCP
complications, trauma, and medication-induced
pancreatitis.
Regarding the endoscopic drainage techniques,
three trials utilized double-pigtail plastic stents com-
bined with nasocystic catheters, while two studies
employed a combination of lumen-apposing metal
stents and double-pigtail plastic stents in EUS-guided
endoscopic drainage.
Additionally, two trials utilized video-assisted retro-
peritoneal debridement, while three trials employed
laparoscopic cystogastrostomy as the MIS approach for
drainage.
3.3. Risk of bias and publication bias
All randomized controlled trials included in our analy-
sis demonstrated a low risk of bias, with negligible
possibility of bias in each study and outcome assessed.
However, given the limited number of studies included
(only 5), we did not explicitly assess the potential for
publication bias.
To assess the influence of individual studies on the
overall results, we conducted a sensitivity analysis by
systematically excluding each study one by one. None
of the studies had a significant impact on the final
results, which remained consistent and unaffected by
the exclusion of any specific study. However, if a study
Figure 1. Flow chart.
Table 1. Characteristics of included studies.
Study Patients Age Male AP ACHE 2 score
Single
organ
failure
Multiple
organ
failure Size of collection
Bakker et al. (2012) [14]SN = 10 64 (46–72) 8 (80) 11 (7–14) 3 1 NA
EN = 10 62 (58–70 6 (60) 10 (6–14) 2 2
Angadi et al. (2021) [24]
RCT
SN = 20 32 (16–60) 18 NA NA NA 1229.4 ± 751.2
EN = 20 36 (21–51) 17 1586.5 ± 505.2
Bang et al. 2019 [15]SN = 32 52.9 (14.2) 21 27.1 (20.3 3 7 10.0 (3.3)
EN = 34 55.6 (14.2) 22 33.7 (13.5) 2 7 10.0 (4.5)
Brunschot et al. (2018)
[16]
SN = 47 60 (11) 29 10 (6–13) 14 7 NA
EN = 51 63 (14) 34 9 (5–13) 13 9
Garg et al. (2020) [20]SN = 30 34.1 ± 12.7 22 NA NA NA 1166.1 ± 1086.1
EN = 30 37.6 ± 12.9 22 1355 ± 827.9
ANNALS OF MEDICINE 5
had demonstrated a substantial impact on the results,
we would have excluded it from our analysis to main-
tain the integrity and reliability of our findings.
3.4. Primary outcome
3.4.1. Major complications
All included studies provided data on major complica-
tions (sudden loss of function or failure of one or
more organs in the body, such as the heart, lungs, or
kidneys, leading to death). The meta-analysis yielded a
risk ratio of 0.69 (95% CI 0.49–0.97), indicating a statis-
tically significant difference in the incidence of major
complications between endoscopic and surgical treat-
ments. The analysis demonstrated moderate heteroge-
neity (I2 = 53%, p = 0.03) among the studies (Figure 2(a)).
These findings suggest that endoscopic treatment is
associated with a lower risk of major complications
compared to surgical treatment.
Table 2. Characteristics of included studies.
Study
Major
complication
and death Death
New
onset of
organ
failure Bleeding
Enterocutaneous
stula or
perforation
Pancreatic
stula
Incisional
hernia or
Use of
enzyme
Percutaneous
drainage
Bakker et al.
(2012)
[14]
8 4 5 0 2 7 NA 3 NA
2 1 0 0 0 1 0
Angadi et al.
(2021)
[24]
7 0 NA 1 1 NA NA 0 3
6 1 1 0 1 3
Bang et al.
(2019)
[15]
13 2 3 3 9 NA 2 NA 6
4 3 2 0 0 0 5
Brunschot
et al.
(2018)
[16]
21 6 6 10 8 13 1 13 NA
22 9 2 11 4 2 0 16
Garg et al.
(2020)
[20]
2 0 NA NA 1 NA NA NA 1
3 0 1 2
Table 3. Characteristics of included studies.
Study
Surgical site
infection
Pancreatic
endocrine
insuciency
Pancreatic exocrine
Insuciency
Length of
hospital stay
Mean procedure
duration
Reccurance or
persistant
Need of
enzyme
Bakker et al.
(2012) [14]
NA 3 3 40.7 (18. 4) NA 3 3
2 0 42.7 (18.4) 2 0
Angadi et al.
(2021) [24]
NA NA NA 6.5 (1.05) 101 (23) NA NA
5 (1.07) 31 (19)
Bang et al.
(2019) [15]
2 9 28 23.3 (17.5) 114.6 (37.2) 5 NA
0 6 29 16.5 (12.2) 53.5 (34.0) 4
Brunschot et al.
(2018) [16]
3 9 13 69 (38) NA NA 16
2 10 16 53 (47) 13
Garg et al.
(2020) [20]
5 NA NA NA NA NA NA
0
6P. TANG ETAL.
3.5. Secondary outcomes
3.5.1. Death or mortality
Among the five included studies, four provided data
on death incidents. The meta-analysis resulted in a
risk ratio of 1.10 (95% CI 0.54–2.23), with no hetero-
geneity (I2 = 0%) and a p-value of 0.80. These find-
ings suggest no significant difference in the number
of deaths between endoscopic and surgical treat-
ments (Figure 2(b)).
Figure 2. Forest plots for (a) major complications, (b) death, (c) bleeding, (d) new onset of organ failure.
ANNALS OF MEDICINE 7
3.5.2. Bleeding
Data on bleeding incidents were available from three
studies. The analysis yielded a risk ratio of 0.80 (95% CI
0.40–1.60), with no heterogeneity (I2 = 0%) and a
p-value of 0.53. These results indicate no significant
difference in the incidence of bleeding between endo-
scopic and surgical treatments (Figure 2(c)).
3.5.3. New onset of organ failure
Three studies provided information on the incidence
of new-onset organ failure. The risk ratio for new cases
of organ failure was 0.29 (95% CI 0.11–0.82), with no
heterogeneity (I2 = 0%) and a p-value of 0.02. These
findings suggest a significant difference in the rate of
new onset of organ failure between endoscopic and
surgical procedures (Figure 2(d)).
3.5.4. Surgical site infection
A risk ratio of 0.26 (95% CI 0.07–0.92) was calculated
for surgical site infection based on three studies, with
no heterogeneity (I2 = 0%) and a p-value of 0.04. These
results indicate a significant difference in the incidence
of surgical site infection between the endoscopic and
surgical treatment groups, with no observed heteroge-
neity (Figure 3(a)).
3.5.5. Fistula or perforation
All five studies included in the analysis reported inci-
dents of fistula or perforation. The meta-analysis
yielded a risk ratio of 0.27 (95% CI 0.12–0.64), with no
heterogeneity (I2 = 0%) and a p-value of 0.003. These
results indicate a significant difference in the incidence
of fistula or perforation between endoscopic and sur-
gical treatments (Figure 3(b)).
3.5.6. Pancreatic stula
Data on pancreatic fistula were reported in only two
of the studies. The analysis resulted in a risk ratio of
0.14 (95% CI 0.05–0.45), with no heterogeneity (I2=0%)
and a p-value of 0.009. These findings suggest a signif-
icant difference in the incidence of pancreatic fistula
between endoscopic and surgical therapies (Figure 3(c)).
3.5.7. Incisional hernia
Only two studies reported incidents of incisional her-
nia in the surgical group with a risk ratio of 0.23 (95%
CI 0.03–2.05), no heterogeneity (I2 = 0%), and a p-value
of 0.19. There was no such complication in the endo-
scopic group (Figure 3(d)).
3.5.8. Need for percutaneous drainage
The analysis of three studies resulted in a risk ratio of
0.97 (95% CI 0.43–2.17), with no heterogeneity (I2 = 0%)
and a p-value of 0.94 for the need for percutaneous
drainage. These findings suggest no significant differ-
ence in the risk ratio for requiring additional percuta-
neous drainage between the endoscopic and surgical
treatment groups (Figure 3 (e)).
3.5.9. Pancreatic endocrine deciency
Three studies reported changes in pancreatic endo-
crine function. The analysis revealed a risk ratio of 0.80
(95% CI 0.46–1.41), with no heterogeneity (I2 = 0%)
and a p-value of 0.45. These findings indicate no sig-
nificant difference in the incidence of pancreatic endo-
crine deficiency between endoscopic and surgical
approaches (Figure 4(a)).
3.5.10. Pancreatic exocrine deciency
An analysis of three studies reporting changes in pan-
creatic exocrine function resulted in a risk ratio of
0.96 (95% CI 0.75–1.23), with minimal heterogeneity
(I2 = 2%) and a p-value of 0.74. These findings sug-
gest no statistically significant difference between
endoscopic and surgical procedures in the incidence
of pancreatic exocrine deficiency following treatment
(Figure 4(b)).
3.5.11. Need for enzyme use
The analysis of three studies reporting the need for
pancreatic enzymes yielded a risk ratio of 0.99 (95% CI
0.56–1.76), with low heterogeneity (I2 = 18%) and a
p-value of 0.97. These results indicate no significant
difference in the incidence of needing pancreatic
enzymes between the endoscopic and surgical treat-
ment groups (Figure 4(c)).
3.5.12. Hospital stay
Four of the included studies reported on hospital stays.
The pooled mean difference was −6.74 days (95% CI
−12.94 to −0.54), with minimal heterogeneity (I2 = 13%)
and a p-value of 0.03. The analysis demonstrated that
endoscopic treatment was associated with a significantly
shorter hospital stay compared to surgical treatment.
Notably, the study by Angadi et al. had a significant
impact on the overall outcome, and therefore, it was
excluded from the hospital stay analysis (Figure 4(d)).
3.5.13. Procedure time
Among the included studies, only two reported the
duration of endoscopic and surgical procedures. The
8P. TANG ETAL.
pooled mean difference was 66.74 min (95% CI −43.92
to 78.14), with no heterogeneity (I2 = 0%) and a
p-value of 0.000. The analysis indicated that
endoscopic treatment required significantly less time
to complete compared to the surgical procedure
(Figure 4(e)).
Figure 3. Forest plots for (a) surgical site infection, (b) stula or perforation, (c) pancreatic stula, (d) incisional hernia, € need for
percutaneous drainage.
ANNALS OF MEDICINE 9
4. Discussion
In this meta-analysis, we examined the efficacy of
endoscopic treatment compared to surgical treatment
for necrotizing pancreatitis by analysing data from five
RCTs involving a total of 284 treated patients. Our
findings revealed that the endoscopic approach yielded
Figure 4. Forest plots for (a) pancreatic endocrine deciency, (b) pancreatic exocrine deciency, (c) need for enzyme use, (d)
hospital stay, (e) procedure time.
10 P. TANG ETAL.
better outcomes than the surgical approach in various
aspects, including overall major complications, fistula
or perforation incidence, hospital stay duration, new
onset of organ failure, pancreatic fistula occurrence,
surgical site infection rates, and procedure time. These
differences were statistically significant.
However, our analysis did not find a statistically sig-
nificant difference between the two treatment
approaches in terms of bleeding incidents, mortality
rates, need for additional percutaneous drainage, pan-
creatic endocrine and exocrine deficiency, and the
requirement for pancreatic enzyme use,. Our
meta-analysis of the RCT studies has shown different
results from the previous studies. Practical and success-
ful management of infected necrotizing pancreatitis
(INP) is necessary as the patient population increases.
The comparative effectiveness of endoscopic and MIS
treatments for INP remains unclear. However, numerous
recent studies have primarily focused on endoscopic
treatment for INP [25–29]. These studies are limited by
small sample sizes and the absence of multi-centre trials.
Medical advancements have resulted in significant
progress in the endoscopic treatment of INP.
Historically, prior to the twentieth century, conservative
management of INP was more prevalent than surgical
intervention [6,30]. However, approximately ten years
ago, surgical treatment in the form of open necrosec-
tomy gained widespread acceptance as a viable
approach for severe pancreatitis [31,32]. In the
twenty-first century, with the advent of MIS, there is
mounting evidence indicating that minimally invasive
approaches are preferable to open surgery [33–37].
Many hospitals now prioritize MIS as the initial treat-
ment option for INP. Recent studies have provided
substantial evidence supporting the benefits of endo-
scopic procedures in the management of infected nec-
rotizing pancreatitis [38–40]. Comparative RCTs
evaluating MIS and endoscopic treatments have
demonstrated comparable outcomes. A meta-analysis
of three studies has shown that an endoscopy-based
treatment strategy significantly reduces complications
compared to MIS in patients with INP [17]. Our analysis
of five RCTs also yielded same results, indicating that
endoscopic approaches statistically exhibit fewer major
complications than MIS. Another meta-analysis com-
prising nine studies focusing on INP treatment demon-
strated that, in comparison to MIS, endoscopic methods
appeared to yield improved short-term outcomes,
including reduced pancreatic fistula incidence and
decreased hospital stay duration [18]. This meta-analysis
corroborated these findings and further indicated that
endoscopic procedures outperformed MIS in various
aspects. Moreover, an additional meta-analysis
involving 190 individuals revealed that endoscopic
treatment offered comparable outcomes to surgical
approaches with added benefits [19]. However, in this
study, incorporated more recent research and pro-
duced divergent results compared to previous studies.
A recently published ExTENSION report of RCT with
a long-term follow-up of 6 months has also demon-
strated that for the treatment of IPN, the endoscopic
step-up strategy was not found to be more effective
than the surgical step-up technique in reducing the
risk of mortality or major complications. However,
patients who received the endoscopic method had a
significantly lower risk of developing pancreatic fistulas
and required fewer reinterventions [41]. In our analysis,
studies showing results of initial follow-up have
demonstrated that the endoscopic approach performs
better than MIS with less major complication, hospital
stay, cases of fistula or perforation as well as new-onset
of organ failure. Long-term follow-up also stated that
the endoscopic approach performs better or the same
as the MIS approach. Another study of 2281 patients
evaluated the management of infected necrotizing
pancreatitis through surgical, endoscopic, or percuta-
neous approaches. The study found that the endo-
scopic approach was associated with the lowest risk of
inpatient mortality (hazard ratio (HR) 0.27; 95% CI
0.08–0.90; p = 0.033), adverse events (p < 0.001), length
of stay (p < 0.001), and total cost [42]. This recent study
also confirms the results of our analysis. A meta-analysis
revealed that the step-up method is the method that
performs substantially better [43]. Many studies have
shown that the endoscopic approach using LAMS is
the best option for the treatment of WON. As it’s a less
invasive and cost-effective option [44,45]. There was a
difference in cost of $41,662 between the two
approaches, with the endoscopic method costing
$75,830 up to 6 months of follow-up and the MIS
method costing $117,492 (p = 0.039) [15]. From ran-
domization to six months after treatment, the endo-
scopic step-up strategy cost €60,228 per patient, while
the surgical step-up strategy costs €73,883 per patient.
The average disparity was €13,655 as a result [16].
Endoscopic treatment of different pancreatobiliary dis-
eases has shown promising results [46–48].
This meta-analysis found that patients who under-
went endoscopic therapy had a shorter hospital stay
compared to those who underwent MIS (p = 03). The
reasons for this difference are likely multifactorial.
Firstly, surgery has a higher threshold for reinterven-
tion following the initial treatment than endoscopy.
Secondly, surgical complications, such as pancreatic
fistula, may require additional interventions or read-
missions. Thirdly, multi-organ failure, which is more
ANNALS OF MEDICINE 11
common in surgical patients, can lead to long-term
morbidity and prolonged hospitalization. The endo-
scopic method has reduced infection risk and reduced
stay, but MIS patients needed long-term care, which
affected life quality, risked infection, caused an exter-
nal pancreatic fistula, and increased expenses. The
endoscopic procedure re-introduces pancreatic fluid
(PF) into the GI tract, preventing electrolytes and fluid
loss compared to the MIS procedure, where PF is
drained out of the body. According to the findings of
a recent study about the quality of life after INP treat-
ment, endoscopic treatment provides a higher overall
quality of life in terms of the patient’s health when
compared to the surgical method [9]. The endoscopic
technique has been demonstrated to yield the same
or comparable results across all of the most recent
investigations. The surgery group had a higher inci-
dence of both newly developed and chronic cardiovas-
cular organ failure [16]. Other single organ failure
incidents were almost same for the both groups. But
there is a need for further investigation with long-term
follow-up to support these results.
Our study has several limitations that should be
acknowledged. Firstly, the final analysis only comprised
five RCTs, and some studies had missing data for cer-
tain outcomes. Furthermore, due to variations in
follow-up duration and protocols among the included
studies, data on recurrence rates and long-term com-
plications were not available for analysis. Another lim-
itation of this meta-analysis is the small sample sizes
of the included studies, which may impact the gener-
alizability of the findings. Furthermore, the major com-
plication (sudden loss of function or failure of one or
more organs in the body, such as the heart, lungs, or
kidneys, leading to death) were not discussed one by
one in detail. Additionally, different types of stents
were used in the studies, introducing potential vari-
ability in the overall results of endoscopic therapy.
Although we employed a fixed-effect model to com-
pare the two groups, certain outcomes exhibited het-
erogeneity, necessitating cautious interpretation of
these findings. Moving forward, there is a need for
larger-scale RCTs that utilize standardized stent types
and treatment approaches to further strengthen the
evidence base in this field.
Conclusion
The findings of this meta-analysis support the prefer-
ence for endoscopic management over surgical treat-
ment for infected necrotizing pancreatitis (INP) based
on its lower complication rate, improved patient qual-
ity of life, and lower associated expenses.
Author contributions
PengHao Tang: Wrote the original manuscript
Kamran Ali: Edit, correct the paper and literature search
Khizar Hayat: Language editing and images editing
Yuanzhi Ni、Zhiwen Cheng、Benfeng Xu、Zhiwen Qin:
Formal analysis and provided article ideas
Wu Zhang: Supervision and article ideas
Disclosure statement
No potential conict of interest was reported by the author(s.)
Data availability
All data generated or analysed during this study are included
in this published article.
Authorship
All named authors meet the International Committee of
Medical Journal Editors (ICMJE) criteria for authorship for
this article, take responsibility for the integrity of the work,
and have given their approval for this version to be
published.
Funding
Research Project of Jinan Microecological Biomedicine
Shandong Laboratory (JNL-2022015B)
ORCID
Kamran Ali http://orcid.org/0000-0002-0304-6130
Hayat Khizar http://orcid.org/0000-0002-9736-1384
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