Minimally invasive necrosectomy vs. conventional surgery in the treatment of infected pancreatic necrosis: a systematic review and a meta-analysis of comparative studies

Aim: The purpose of this meta-analysis and systematic review is to compare minimally invasive necrosectomy (MIN) versus open surgery (ON) for infected necrosis of acute pancreatitis. Methods: One Randomized Controlled Trial (RCT) and three Clinical Controlled Trial (CCT) were selected with a total of 336 patients included (215 patients who underwent MIN and 121 patients underwent ON) after searching in the following databases: Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, Science Citation Index (from inception to August 2011), Greynet, SIGLE, National Technological Information Service, British Library Integrated catalogue, Current Controlled Trials and the Cochrane Central Register of Controlled Trials. Statistical analysis is performed using the Odds ratio (OR) and Weighted mean difference (WMD) with 95% confidence interval. Results: After the analysis of the data amenable to poling a significant advantages were found in favor of the MIN in terms of: incidence of multiple organ failure (MOF) (OR 0.16; 95% CI 0.06 to 0.39) (P <0.0001), incisional hernias (OR 0.23; 95% CI 0.06 to 0.90) (P= 0.03), new-onset diabetes (OR 0.32; 95% CI 0.12 to 0.88) (P= 0.03) as well for the use of pancreatic enzymes (OR 0.005; 95% CI 0.04 to 0.57) (P= 0.005). No differences were found in terms of mortality rate (OR 0.43; 95% CI 0.18 to 1.05) (P= 0.06), multiple systemic complication (OR 0.34; 95% CI 0.01 to 8.60) (P=0.51), surgical re-intervention for further necrosectomy (OR 0.16; 95% CI 0.00 to 3.07) (P= 0.19), intraabdominal bleeding (OR 0.79; 95% CI 0.41 to 1.50) (P= 0.46), entero-cutaneous fistula or perforation of visceral organs (OR 0.52; 95% CI 0.27 to 1.00) (P= 0.05), pancreatic fistula (OR 0.66; 95% CI 0.30 to 1.46) (P= 0.30), and surgical reintervention for post-operative complications (OR 0.50; 95% CI 0.23 to 1.08) (P= 0.08). Conclusion: The lacking of comparative studies and the high heterogeneity of the data present in the literature did not permit to draw definitive conclusion on this topic. The results of present metanalysis might be helpful to design future high powered randomized studies which compare MIN versus ON for acute necrotizing pancreatitis.