title: Pancreatic necrosectomy: an evidence-based systematic review of the levels of evidence and a comparison of endoscopic versus non-endoscopic techniques.
abstract: BACKGROUND
  Endoscopic necrosectomy is now becoming common worldwide as a minimally-invasive treatment alternative to surgical necrosectomy. The aims of this systematic review are to record the entire body of the literature accumulated over the past 15 years on endoscopic necrosectomy techniques and to compare the outcomes of endoscopic versus non-endoscopic techniques.
  
  
  METHODS
  All relevant articles were extracted up to December 2015 based on the results of searches in PubMed, Scopus and Google Scholar.
  
  
  RESULTS
  A total of 46 pertinent articles were finally included for the purpose of this systematic review. Most of the studies in our review included small numbers of patients, were retrospective and had low/moderate overall levels of evidence. The mean technical and clinical success rates reported were 99% and 89%, respectively, the mean overall complication rate was 22% and the mean overall mortality rate was 5%. The most common complications were bleeding, which occurred in 11% of patients, perforations/pneumoperitoneum which occurred in 3%, and air embolism in 0.4% of patients. The access to the cavity was created by direct endoscopic puncture in 205 patients, while endoscopic ultrasound guidance was used in 733, with no difference in technical success (99% vs. 99%), clinical success (87% vs. 89%), complications (32% vs. 21%) and mortality (7% vs. 5%) rates. Compared to the percutaneous and surgical therapies, the endoscopic techniques exhibited higher success rates and lower morbidity and mortality rates.
  
  
  CONCLUSIONS
  Endoscopic necrosectomy is becoming the standard of care for the treatment of pancreatic necrotic collections.
authors.affiliation: Unit of Digestive Endoscopy, San Paolo Hospital, Milan, Italy - carmeluigiano@libero.it.
authors.forename: Carmelo
authors.initials: C
authors.lastname: Luigiano
authors.forename: Rinaldo
authors.initials: R
authors.lastname: Pellicano
authors.forename: Pietro
authors.initials: P
authors.lastname: Fusaroli
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Iabichino
authors.forename: Monica
authors.initials: M
authors.lastname: Arena
authors.forename: Andrea
authors.initials: A
authors.lastname: Lisotti
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Consolo
authors.forename: Carmela
authors.initials: C
authors.lastname: Morace
authors.forename: Enrico
authors.initials: E
authors.lastname: Opocher
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Caletti
authors.forename: Sharmila
authors.initials: S
authors.lastname: Fagoonee
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Cennamo
authors.forename: Carlo
authors.initials: C
authors.lastname: Fabbri
mesh_terms: D003646:Debridement / Q000379:methods*; D004322:Drainage / Q000379:methods; D004384:Duodenoscopy / Q000379:methods*; D019317:Evidence-Based Medicine; D006801:Humans; D015201:Meta-Analysis as Topic; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods; D019283:Pancreatitis, Acute Necrotizing / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000379:methods