The optimal timing and intervention to reduce mortality for necrotizing pancreatitis: a systematic review and network meta-analysis

Abstract

Background A series of randomized controlled trials have investigated the efficacy and safety of different timings of interventions and methods of intervention. However, the optimal treatment strategy is not yet clear. Methods We searched PubMed, EMBASE, ClinicalTrials.gov and the Cochrane Library until November 30, 2022. A systematic review and Bayesian network meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Trials comparing different treatment strategies for necrotizing pancreatitis were included. This study was registered in the Prospective Register of Systematic Reviews (CRD42022364409) to ensure transparency. Results We analyzed a total of 10 studies involving 570 patients and 8 treatment strategies. Although no statistically significant differences were identified comparing odds ratios, trends were confirmed by the surface under the cumulative ranking (SUCRA) scores. The interventions with a low rate of mortality were delayed surgery (DS), delayed surgical step-up approach (DSU) and delayed endoscopic step-up approach (DEU), while the interventions with a low rate of major complications were DSU, DEU and DS. According to the clustered ranking plot, DSU performed the best overall in reducing mortality and major complications, while DD performed the worst. Analysis of the secondary endpoints confirmed the superiority of DEU and DSU in terms of individual components of major complications (organ failure, pancreatic fistula, bleeding, and visceral organ or enterocutaneous fistula), exocrine insufficiency, endocrine insufficiency and length of stay. Overall, DSU was superior to other interventions. Conclusion DSU was the optimal treatment strategy for necrotizing pancreatitis. Drainage alone should be avoided in clinical practice. Any interventions should be postponed for at least 4 weeks if possible. The step-up approach was preferred.

A Case of Life-Threatening Postpartum Necrotizing Pancreatitis Requiring Gastrocystostomy With Serial Pancreatic Necrosectomies

“…In acute pancreatitis, intrapancreatic activation of pancreatic enzymes causes direct cellular and tissue injury, with proteolytic and lipolytic enzymatic activities leading to parenchymal necrosis [ 5 , 6 ]. This case is an unfortunate example of how volatile acute necrotizing pancreatitis can be and raises several questions.…”

“…A clinical diagnosis of acute pancreatitis can be made with two of the following three: characteristic abdominal pain (sharp, stabbing, radiating to the back), a marked elevation in pancreatic enzymes (lipase, amylase), and abdominal imaging consistent with pancreatic inflammation. Approximately 20% of patients with acute pancreatitis are complicated by the necrotizing form of the disease, which carries a mortality risk as high as 20-30% [ 5 , 6 ]. Rates are likely higher in postpartum patients, although the true rate remains unknown and there is little speculation in the literature as to a definite cause.…”

RNA-sequencing approach for exploring the protective mechanisms of dexmedetomidine on pancreatic injury in severe acute pancreatitis

“…Early detection and active treatment are essential to improve the prognosis of severe acute pancreatitis. In the acute phase, SAP patients usually require admission to the intensive care unit for symptomatic treatment such as mechanical ventilation, fluid resuscitation, or renal replacement therapy ( Yang, et al, 2023 ). Dex reacts with α2 adrenergic receptors in the central nervous system, decreases sympathetic activity, leading to a shift in balance to the parasympathetic nervous system (including the vagus nerve), and is widely used in the intensive care unit ( Wiegand, et al, 2023 ).…”

Endoscopic versus minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials

“…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.…”