Post written Masahiro Tsujimae, MD, PhD, from the Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, and Yousuke Nakai, MD, PhD, from the Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo, Japan.

The aim of our study was to investigate associations of the use of endoscopic necrosectomy (EN) and its timing with clinical outcomes of EUS-guided treatment for walled-off necrosis (WON) using large data from a multi-institutional cohort within the WONDERFUL study group in Japan.

The advent of lumen-apposing metal stents has made a paradigm shift in the treatment of WON by serving as a transluminal port for efficient EN. However, to our knowledge, there has been a paucity of evidence for the role of EN in this context and the appropriate timing of initiating EN after EUS-guided drainage.

In our multicenter retrospective cohort study of 153 patients requiring step-up treatment after EUS-guided drainage, EN was associated with a significantly shorter time to clinical success compared with drainage alone (subdistribution hazard ratio, 1.66; 95% confidence interval, 1.12-2.46).

Importantly, there were no significant differences in the rates of severe adverse events (7.8% for EN vs 5.9% for non-EN) or mortality (6.9% vs 9.8%). EN was associated with a higher incidence of procedure-related bleeding (26.5% vs 9.8%), although most cases were nonsevere.

In addition, EN reduced the need for additional procedures, such as percutaneous or surgical drainage. Meanwhile, the timing of EN—categorized as 0 to 14 days, 15 to 28 days, or ≥29 days from initial drainage—did not significantly affect the time to clinical success (P_trend = .34).

In conclusion, EN-based step-up treatment may lead to faster resolution of WON without increasing the risk of severe adverse events or mortality compared with drainage-based strategies. However, the optimal timing of EN remains unclear.

The DESTIN (Randomized Trial of Immediate Endoscopic Necrosectomy vs Step-up Endoscopic Interventions in Necrotizing Pancreatitis) trial¹ demonstrated upfront EN at the time of EUS-guided drainage could safely reduce the number of reinterventions. Further prospective studies—including our WONDER-01 (Immediate Necrosectomy vs Step-up Approach for Walled-off Necrosis) randomized controlled trial² (ClinicalTrials.gov NCT05451901)—are needed to better define the safety, efficacy, and cost-effectiveness between early EN versus delayed EN.

Cumulative incidence curves of clinical treatment success after EUS-guided drainage of walled-off necrosis according to treatment strategies. P values were calculated by using the Gray test: A, Endoscopic necrosectomy (EN) vs non-EN (drainage). B, According to the timing of initiating EN.

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1. Bang JY, Lakhtakia S, Thakkar S, et al. Upfront endoscopic necrosectomy or step-up endoscopic approach for infected necrotising pancreatitis (DESTIN): a single-blinded, multicentre, randomised trial. Lancet Gastroenterol Hepatol 2024;9:22-33. ↩︎
2. Sato T, Saito T, Takenaka M, et al. WONDER-01: immediate necrosectomy vs. drainage-oriented step-up approach after endoscopic ultrasound-guided drainage of walled-off necrosis-study protocol for a multicentre randomised controlled trial. Trials 2023;24:352. ↩︎

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