Expanding minimally invasive treatment approaches for refractory large walled‐off necrosis after necrotizing pancreatitis

A minimally invasive treatment approach, especially an endoscopic step-up approach from endoscopic ultrasound-guided transluminal drainage (EUS-TD) to endoscopic necrosectomy through the created fi stula, is now recom-mended as the fi rst-line treatment for symptomatic walled-off necrosis (WON). 1 Furthermore, with the development and availability of large-bore bi fl anged metal stents for EUS-TD, such as lumen-apposing metal stents, which facilitate additional procedures, particularly endoscopic necrosectomy, the clinical outcomes of endoscopic therapy for WON have been improving. 2 However, the morphology of WON may be small unilocular, complicated multilocular, or large extending from a peripancreatic lesion to the pelvic cavity. The optimal treatment approach and its dif fi culty depends on the size, location, morphology, and amount of necrotic tissue, and data from previous studies should be interpreted with this in mind. 3 A recent retrospective study by Gupta et al . 4 that included 119 patients showed a signi fi cant association between the extent of extrapancreatic necrosis and clinical outcomes, including length of hospital stay, length of stay in the intensive care unit, and mortality. Moreover, studies usefulness step-up necrosis 15 cm). that that the remains

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