TOPLINE:

Compared with the standard endoscopic step-up treatment approach, an accelerated endoscopic approach significantly reduced both the incidence of major complications and the length of hospital stay in patients with large walled-off pancreatic necrosis.

METHODOLOGY:

• Prolonged hospital stays and major complications are common with the standard endoscopic step-up treatment approach for walled-off pancreatic necrosis. Although an accelerated endoscopic approach may offer an outcome benefit, its effectiveness in larger, complex cases remains uncertain.
• Researchers conducted a trial to compare the efficacy and safety of an accelerated endoscopic protocol with the standard step-up endoscopic approach in patients with symptomatic walled-off pancreatic necrosis greater than 15 cm in diameter.
• Patients were randomly assigned either to the accelerated treatment group (n = 12; median age, 56.5 years; 42% women) or the step-up treatment group (n = 13; median age, 53 years; 39% women).
• In the accelerated group, endoscopic necrosectomy was performed during the initial drainage procedure, and additional treatments such as endoscopic necrosectomy, endoscopic or percutaneous drainage, and video-assisted retroperitoneal debridement were performed subsequently as often as clinically indicated to resolve the necrosis. In the step-up group, endoscopic necrosectomy was not performed at initial drainage, and necrosectomy, drainage, or debridement were performed only if clinical improvement was not achieved.
• The primary endpoint was a composite of death, major complications, and length of hospital stay exceeding 58 days, assessed within 6 months after randomization. Secondary endpoints included change over time in C-reactive protein and albumin levels, and white blood cell count.

TAKEAWAY:

• The accelerated group showed significantly better outcomes than the step-up group, with the primary composite endpoint occurring in 8.3% vs 61.5% of patients (risk ratio, 0.14; P = .011).
• The incidence of major complications was significantly lower in the accelerated group than in the step-up group (0% vs 46.2%; P = .015), and median length of hospital stay was shorter (32.5 vs 68.5 days; P = .039).
• Within the first 10 days, levels of C-reactive protein decreased by 9.8 mg/L per day in the accelerated group but increased by 5.9 mg/L per day in the step-up group (P < .001). Albumin levels increased more per day in the accelerated vs step-up group, but there was no significant change in white blood cell count in either group.

IN PRACTICE:

“While the endoscopic step-up approach has long been considered the gold standard for managing symptomatic WON [walled-off necrosis], our findings suggest that an accelerated approach can further optimize outcomes as it differs fundamentally by performing necrosectomy during the initial drainage session and has no restrictions for further necrosectomy or additional drainage,” the authors wrote.

SOURCE:

This study, led by Gitte Aabye Olsen, MD, Pancreatitis Centre East, Gastro Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark, was published online in Clinical Gastroenterology and Hepatology.

LIMITATIONS:

The early termination of the trial due to concern for the safety of patients in the step-up group may have affected the stability and precision of the effect-size estimates. The small sample limited the power to assess the risk for mortality and specific major complications such as bleeding, organ failure, or enterocutaneous fistulas. Additionally, the trial was conducted at a single tertiary referral center with experienced endoscopists, which may have limited generalization of the results.

DISCLOSURES:

This study was partly supported by The Novo Nordisk Foundation. Two authors declared being consultants for Ambu and Boston Scientific, and one is also a consultant for SNIPR BIOME and Biodexa.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.