Comparison of treatment approaches for infected necrotizing pancreatitis: a systematic review and network...

This study aimed to compare the outcomes of various treatment approaches for infected necrotizing pancreatitis.

A literature search was performed in November 2024 to identify studies comparing upfront open necrosectomy (UOPN), upfront minimally invasive necrosectomy (UMIN), surgical step-up (SSU), upfront endoscopic necrosectomy (UEN), and endoscopic step-up (ESU) approaches. The primary outcome was mortality. A network meta-analysis was conducted to assess the relative effectiveness of these approaches. A cost-effectiveness analysis (CEA) was performed using a decision model, incorporating net monetary benefit (NMB) and predefined willingness-to-pay (WTP) thresholds to evaluate the economic efficiency of each treatment strategy.

A total of 21 studies involving 1850 patients were included. UEN consistently ranked the highest across 11 outcomes, with the significantly lowest risks of mortality, complications, new-onset organ failure, and the shortest overall hospital length of stay. In addition, the ESU approach showed favorable results, including lower risks of complications, pancreatic fistula, enterocutaneous or gastrointestinal fistula, visceral perforation, and incisional hernia compared with other strategies. UOPN consistently ranked the lowest. UMIN and the SSU approach ranked midrange for most outcomes. The CEA identified endoscopic approaches as the most cost-effective, with the lowest cost ($95,156.02), the highest effectiveness (34.1 days of earlier recovery), and the highest NMB ($3,314,843.98). The endoscopic approach had a 97.2% probability of cost-effectiveness at a $100,000 WTP threshold.

When anatomical access permits, endoscopic approaches are likely to offer optimal clinical outcomes and cost-effectiveness for managing infected necrotizing pancreatitis.