# The Experience of a Tertiary Referral Center with Endoscopic Management and Combining Percutaneous Intervention for the Treatment of Walled-Off Necrosis: A Stepwise Approach

## TL;DR

This study shows that endoscopic treatment is effective for walled-off necrosis, but combining it with percutaneous intervention improves success in complex cases.

## Contribution

The study introduces a stepwise approach combining endoscopic and percutaneous interventions for treating complex walled-off necrosis.

## Key findings

- Endoscopic management achieved 90.9% technical success but only 36.3% clinical success.
- Combining percutaneous intervention achieved 100% success in cases where endoscopic treatment failed.
- Major complications occurred in two patients, including one death due to perforation.

## Abstract

Background: This study aimed to assess the effectiveness and safety of endoscopic management in patients with walled-off necrosis and additionally explore the results of a stepwise approach for combining percutaneous intervention in cases where endoscopic management was inadequate. Methods: We included cases of endoscopic management for walled-off necrosis between February 2019 and December 2023. Results: Endoscopic management was performed in 11 patients. The median largest dimension was 150 mm. Multiple cavities were present in four patients. Technical success was 90.9%, while clinical success with only endoscopic management was 36.3%. Clinical success could not be achieved with only endoscopic management in patients with a large diameter (≥125 mm) or multi-lobulated walled-off necrosis. Combining percutaneous intervention resulted in success for all patients. Two patients experienced major complications: one suffered from major bleeding, while the other experienced perforation, necessitating surgical intervention. The patient with perforation died due to multi-organ failure. Conclusions: Endoscopic management is recommended as the primary treatment method for walled-off necrosis due to its less invasive and higher safety profile. In cases involving large or multi-lobulated walled-off necrosis where clinical success cannot be achieved, combining percutaneous intervention is highly successful and safe. Ultimately, this approach can minimize the need for more invasive surgery.