This is the Scientific Surgery Archive, which contains all randomized clinical trials in surgery that have been identified by searching the top 50 English language medical journal issues since January 1998. Compiled by Jonothan J. Earnshaw, former Editor-in-Chief, BJS

Outcomes after implementing a tailored endoscopic step‐up approach to walled‐off necrosis in acute pancreatitis. BJS 2014; 101: 1729-1738.

Published: 21st October 2014

Authors: J. Y. Bang, B. A. Holt, R. H. Hawes, M. K. Hasan, J. P. Arnoletti, J. D. Christein et al.

Background

The aim of the study was to compare the outcomes of patients with pancreatic or peripancreatic walled‐off necrosis by endoscopy using the conventional approach versus an algorithmic approach based on the collection size, location and stepwise response to intervention.

Method

This was an observational before–after study of consecutive patients managed over two time intervals. In the initial period (2004–2009) symptomatic patients with walled‐off necrosis underwent conventional single transmural drainage with placement of two stents and a nasocystic catheter, followed by direct endoscopic necrosectomy, if required. In the later period (2010–2013) an algorithmic approach was adopted based on size and extent of the walled‐off necrosis and stepwise response to intervention. The main outcome was treatment success, defined as a reduction in walled‐off necrosis size to 2 cm or less on CT after 8 weeks.

Results

Forty‐seven patients were treated in the first interval and 53 in the second. There was no difference in patient demographics, clinical or walled‐off necrosis characteristics and laboratory parameters between the groups, apart from a higher proportion of women and Caucasians in the later period. The treatment success rate was higher for the algorithmic approach compared with conventional treatment (91 versus 60 per cent respectively; P < 0·001). On multivariable logistic regression, management based on the algorithm was the only predictor of treatment success (odds ratio 6·51, 95 per cent c.i. 2·19 to 19·37; P = 0·001).

Conclusion

An algorithmic approach to pancreatic and peripancreatic walled‐off necrosis, based on the collection size, location and stepwise response to intervention, resulted in an improved rate of treatment success compared with conventional endoscopic management.

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