微创和内镜下与开放性坏死组织清除术治疗坏死性胰腺炎：对 1980 名患者的个体数据进行的汇总分析。

Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients.

机构信息

Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands.

Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.

出版信息

Gut. 2018 Apr;67(4):697-706. doi: 10.1136/gutjnl-2016-313341. Epub 2017 Aug 3.

DOI:10.1136/gutjnl-2016-313341

PMID:28774886

Abstract

OBJECTIVE

Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking.

DESIGN

We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%).

RESULTS

Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005).

CONCLUSION

In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.

摘要

目的

与开放性坏死组织清除术相比，微创外科坏死组织清除术和内镜下坏死组织清除术可能改善坏死性胰腺炎的预后，尤其是在重症患者中。缺乏来自大型对照研究的证据。

设计

我们结合了 15 项已发表和未发表的患者队列研究（51 家医院；8 个国家）的原始和新收集的数据，这些研究涉及胰腺坏死组织清除术治疗坏死性胰腺炎。比较了接受开放性坏死组织清除术与微创外科或内镜下坏死组织清除术的患者的死亡率。为了调整混杂因素，并研究临床严重程度的效应修饰，我们进行了两种类型的分析：逻辑多变量回归和基于基线死亡风险预测的倾向评分匹配（分层为低：<5%；中：≥5%至<15%；高：≥15%至<35%；极高：≥35%）。

结果

在 1980 例坏死性胰腺炎患者中，1167 例行开放性坏死组织清除术，813 例行微创外科（n=467）或内镜下（n=346）坏死组织清除术。微创外科坏死组织清除术（OR，0.53；95%CI，0.34 至 0.84；p=0.006）和内镜下坏死组织清除术（OR，0.20；95%CI，0.06 至 0.63；p=0.006）的死亡风险较低。在风险分层的倾向评分匹配后，在极高危组中，微创外科坏死组织清除术仍与开放性坏死组织清除术相比，死亡风险较低（42/111 比 59/111；风险比，0.70；95%CI，0.52 至 0.95；p=0.02）。在内镜下坏死组织清除术组中，与开放性坏死组织清除术相比，高危组（3/40 比 12/40；风险比，0.27；95%CI，0.08 至 0.88；p=0.03）和极高危组（12/57 比 28/57；风险比，0.43；95%CI，0.24 至 0.77；p=0.005）的死亡率较低。