ArticleSurgical endoscopy2026
Management of walled-off pancreatic necrosis (WON) beyond the conventional step-up strategy: a retrospective cohort study.
Article in Surgical endoscopy, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
objectivesEndoscopic transmural drainage and necrosectomy (ETDN) is a well-established technique for managing walled-off pancreatic necrosis (WON). However, ETDN may be insufficient in some cases, necessitating adjunctive techniques such as video-assisted retroperitoneal debridement (VARD) or endoscopic ultrasound-guided transcolonic drainage and necrosectomy (EUS-TC). The optimal step-up strategy in these patients remains unclear. We aimed to assess management of WON beyond the reach of ETDN.
methodsPatients with WON undergoing EUS-TC or VARD were identified from a prospectively maintained database between 2017 and 2024.
resultsForty-five consecutive patients (median age 53 years; median WON size 24 cm) were included, with a median follow-up of 19 months. Thirty-three patients (73%) underwent VARD, and 12 patients (27%) underwent EUS-TC. The median length of stay (LOS) was 85 days (IQR 48-126) for the VARD group and 74 days (IQR 40-152) for the EUS-TC group, and did not differ significantly (p = 0.818). In-hospital mortality was 18% (n = 8), all due to organ failure, with no difference between the two groups, p = 0.661. Thirty-seven (82%) patients achieved complete resolution (28 VARD, 9 EUS-TC). Overall, 10 (27%) patients (eight in VARD group and 3 in EUS-TC group, one patient was treated with both VARD and EUS-TC) developed 12 external fistulas (10 enterocutaneous (six colo-cutaneous, four small bowel) and two pancreatico-cutaneous. All pancreatico-cutaneous fistulas were managed conservatively, whereas all six patients with colo-cutaneous fistulas necessitated intervention.
conclusionsEUS-TC and VARD are both viable options for managing transgastrically inaccessible WON, although management remains associated with substantial LOS and external fistula formation.
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