Treatment for Infected Pancreatic Necrosis Should be Delayed, Possibly Avoiding an Open Surgical Approach: A Systematic Review and Network Meta-analysis

OBJECTIVE: To evaluate all invasive treatments for suspected IPN. SUMMARY OF BACKGROUND DATA: The optimal invasive treatment for suspected IPN remains unclear. METHODS: A systematic search of randomized clinical trials comparing at least 2 invasive strategies for the treatment of suspected IPN was carried out. A frequentist random-effects network meta-analysis was made reporting the surface under the cumulative ranking (SUCRA). The primary endpoint regarded both the in-hospital mortality and major morbidity rates. The secondary endpoints were mortality, length of stay, intensive care unit stay, the pancreatic fistula rate, and exocrine and endocrine insufficiency. RESULTS: Seven studies were included, involving 400 patients clustered as following: 64 (16%) in early surgical debridement (ED); 27 (6.7%) in peritoneal lavage (PL); 45 (11.3%) in delayed surgical debridement (DD), 169 (42.3%) in the step-up approach with minimally invasive debridement (SUA-DD) and 95 (23.7%) with endoscopic debridement (SUA-EnD). The step-up approach with endoscopic debridement had the highest probability of being the safest approach (SUCRA 87.1%), followed by SUA-DD (SUCRA 59.5%); DD, ED, and PL had the lowest probability of being safe (SUCRA values 27.6%, 31.4%, and 44.4%, respectively). Analysis of the secondary endpoints confirmed the superiority of SUA-EnD regarding length of stay, intensive care unit stay, pancreatic fistula rate, and new-onset diabetes. The SUA approaches are similar regarding exocrine function. Mortality was reduced by any delayed approaches (DD, SUA-DD, or SUA-EnD). CONCLUSIONS: The first choice for suspected IPN seemed to be SUA-EnD. An alternative could be SUA-DD. PL, ED, and DD should be avoided.