title: Outcomes after implementing a tailored endoscopic step-up approach to walled-off necrosis in acute pancreatitis.
abstract: 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.
  
  
  METHODS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Centers for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA.
authors.forename: J Y
authors.initials: JY
authors.lastname: Bang
authors.forename: B A
authors.initials: BA
authors.lastname: Holt
authors.forename: R H
authors.initials: RH
authors.lastname: Hawes
authors.forename: M K
authors.initials: MK
authors.lastname: Hasan
authors.forename: J P
authors.initials: JP
authors.lastname: Arnoletti
authors.forename: J D
authors.initials: JD
authors.lastname: Christein
authors.forename: C M
authors.initials: CM
authors.lastname: Wilcox
authors.forename: S
authors.initials: S
authors.lastname: Varadarajulu
mesh_terms: D000328:Adult; D000465:Algorithms; D002404:Catheterization / Q000379:methods; D004322:Drainage / Q000379:methods; D016145:Endoscopy, Digestive System / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019283:Pancreatitis, Acute Necrotizing / Q000209:etiology / Q000601:surgery*; D011446:Prospective Studies; D012189:Retrospective Studies; D015607:Stents; D016896:Treatment Outcome