Comparison of Direct Endoscopic Necrosectomy With Endoscopic Step-Up Approach After Endoscopic Drainage of Pancreatic Walled-Off Necrosis: Systematic Review and Meta-Analysis.

Background and study aims: Direct endoscopic necrosectomy (DEN) is a safe and effective option in the treatment of pancreatic walled-off necrosis (WOPN). Whether DEN should be performed immediately after drainage (DEN) or as a step-up approach (SUA) is unknown. The aim of this meta-analysis was to compare SUA with DEN in the treatment of WOPN.

Patients and methods: Electronic databases including EMBASE, PubMed and Cochrane Library were searched for studies on DEN and SUA using equivalent combinations of "DEN," "Endoscopic step-up approach," and "Walled-off necrosis." Studies were included only if they reported all primary outcomes of interest: (1) clinical success, defined as resolution of clinical symptoms of WOPN at 6 months and (2) postprocedural adverse events. Secondary outcomes were technical success, number of additional DEN required and reintervention rate, defined as number of additional DEN and other interventions required per patient.

Results: In this study, 1290 patients from 15 studies were included. There were no significant differences in clinical success (SUA: 94%, 95% CI: [91%-96%]; DEN: 90%, 95% CI: [83%-94%]; p = 0.14), adverse events (SUA: 16%, 95% CI: [10%-24%]; DEN: 16%, 95% CI: [10%-24%]; p = 0.97), technical success (SUA: 99%, 95% CI: [98%-99%]; DEN: 98%, 95% CI: [95%-99%]; p = 0.07), reinterventions (SUA: 1.48, 95% CI: [0.80-2.17]; DEN: 0.99, 95% CI: [0.48-1.51]; p = 0.26), and number of additional DEN required per patient (SUA: 0.93, 95% CI: [0.45-1.39]; DEN: 1.24, 95% CI: [0.57-1.92]; p = 0.44).

Conclusions: SUA and DEN were comparable in clinical success, adverse events, technical success, reinterventions, and additional DEN required.