Interventions for walled off necrosis using an algorithm based endoscopic step-up approach: Outcomes in a large cohort of patients

Yukako Nemoto, Rajeev Attam, Mustafa A. Arain, Guru Trikudanathan, Shawn Mallery, Gregory J. Beilman, Martin L. Freeman

Research output: Contribution to journalArticlepeer-review

34 Scopus citations


Objectives The minimally invasive step-up approach for treatment of walled off necrosis (WON) involves drainage followed by later necrosectomy as needed, and is superior to primary surgical necrosectomy. Reported series of endoscopic transluminal necrosectomy include highly selected patients. We report outcomes of a large series of patients with WON managed by an algorithm based on an endoscopically centered step-up approach. Methods Consecutive patients with necrotizing pancreatitis from 2009 to 2014, with intervention only for infected or persistently symptomatic WON. The primary approach involved endoscopic transluminal drainage plus minus necrosectomy whenever feasible, with percutaneous catheter drainage (PCD) plus minus sinus tract endoscopy if not feasible or sufficient. Surgery was reserved for failures of the step up approach. Results Of 109 consecutive patients with necrotizing pancreatitis, intervention was required in 83, including endoscopic transluminal drainage in 73 (88%) (alone in 49 and combined with PCD in 24), and PCD alone in 10 (12%). 64 (77%) of the 83 patients required endoscopic transluminal and/or sinus tract necrosectomy. Adverse events occurred in 11 (13%). Three patients (4%) failed step up approach and required open surgical necrosectomy. All-cause mortality occurred in 6 (7%) of 83 patients after intervention, including 2 of 3 requiring surgery. Conclusions An algorithm based step-up approach for interventions in necrotizing pancreatitis using primarily endoscopic techniques with adjunctive percutaneous approaches as needed resulted in favorable outcomes with small numbers proceeding to open surgery, and with acceptable rates of major complications and mortality. A purely endoscopic transluminal approach was feasible in approximately 60% of patients requiring intervention in this series.

Original languageEnglish (US)
Pages (from-to)663-668
Number of pages6
Issue number5
StatePublished - Sep 2017

Bibliographical note

Funding Information:
M.L.F. has served as a consultant for Boston Scientific and XLumena, has received speaking honoraria from Cook Endoscopy, and has been an unpaid consultant to Hobbs Medical Inc. S.K.A serves as consultant for Boston Scientific and Merit Endoscopy R.A. has served as consultant for Boston Scientific and Cook Endoscopy. Preliminary results of the study were presented at an American Pancreatic Association annual meeting.

Publisher Copyright:
© 2017 IAP and EPC


  • Endoscopic transluminal drainage
  • Endoscopic transluminal necrosectomy
  • Endoscopic ultrasound
  • Walled off necrosis


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