Management of walled-off pancreatic necrosis (WON) beyond the conventional step-up strategy: a retrospective cohort study

Objectives: Endoscopic 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. Methods: Patients with WON undergoing EUS-TC or VARD were identified from a prospectively maintained database between 2017 and 2024. Results: Forty-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. Conclusions: EUS-TC and VARD are both viable options for managing transgastrically inaccessible WON, although management remains associated with substantial LOS and external fistula formation.