A Comparative Study between Endoscopic Transmural Drainage and Direct Endoscopic Necrosectomy in Acute Necrotizing Pancreatitis

Background: Acute necrotizing pancreatitis occurs in 10%–20% of patients with acute pancreatitis which is one of the most important acute abdominal diseases that require hospital admission. In the past 20 years, the treatment of pancreatic necrosis has shifted from open necrosectomy to minimally invasive techniques, such as endoscopic interventions. With the development of endoscopic techniques, the safety and effectiveness of endoscopic interventions have improved, but there exist several unresolved problems. Endoscopic transmural drainage (ETD) and Direct endoscopic necrosectomy (DEN)—often performed via Endoscopic Ultrasoundguided (EUS-guided) techniques—have emerged as the preferred, less-invasive, first-line, or "step-up" approach for managing walled-off pancreatic necrosis (WON) and infected necrotizing pancreatitis (INP), significantly reducing morbidity compared to traditional surgical necrosectomy. Aim: It was aimed to compare the outcomes of minimally invasive surgery vs endoscopic approaches for patients with infected necrotizing pancreatitis. Methods: A total of 90 patients, aged 18-70, both sexes with confirmed or suspected infected necrotizing pancreatitis, randomly divided into two groups. Patients were randomly assigned to groups that received minimally invasive surgery (Direct Endoscopic Necrosectomy, DEN, N=44) or Endoscopic Transmural Drainage ETD, N=46). The primary endpoint was a composite of major complications (new-onset multiple organ failure, new-onset systemic dysfunction, enteral or pancreatic-cutaneous fistula, bleeding and perforation of a visceral organ) or death during 6 months of follow-up. Results: None of the patients assigned to the ETD approach developed enteral or pancreatic-cutaneous fistulae compared with 12/27.27% of the patients who underwent DEN (P=0.01). The mean number of major complications per patient was significantly higher in the DEN group (0.69 ± 1.03) compared with the endoscopy group (0.15 ± 0.44) (P=0.05). The physical health scores for quality of life at 3 months was better with the ETD approach (P =0.39) and mean total cost was lower as compared to DEN (P =0.03). Conclusion: In a randomized trial of 90 patients, an endoscopic transluminal (ETD) approach for infected necrotizing pancreatitis, compared with minimally invasive surgery (DEN), significantly reduced major complications, lowered costs, and increased quality of life.