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• W4380204601 abstract "We read with great interest the article by Baroud et al,1Baroud S. et al.Clin Gastroenterol Hepatol. 2023; (in press)PubMed Google Scholar which reported a retrospective investigation of new criteria for determining the timing of step-up interventions for pancreatic walled-off necrosis (WON), after initial transluminal drainage. Compared with a physician-oriented, on-demand approach, the algorithmic approach based on a cut-off value of 50% for a decreased rate of WON size over 2 weeks was associated with better clinical outcomes. There has been a long-standing controversy over the optimal timing of step-up interventions (eg, direct endoscopic necrosectomy) for WON.2Sato T. et al.DEN Open. 2023; 3: e182Crossref PubMed Google Scholar Intuitively, early administration of intensive treatment may shorten the time to clinical success in this setting.3Yan L. et al.Endosc Ultrasound. 2019; 8: 172-179Crossref PubMed Scopus (43) Google Scholar However, the risk of procedure-related adverse events may be increased as a result of multiple factors including insufficient collection encapsulation and a sustained inflammatory reaction in the pancreas. A landmark randomized trial by the Dutch pancreatitis group provided the rationale for delaying subsequent interventions by showing the potential of this treatment strategy to partly avoid unnecessary additional interventions.4Boxhoorn L. et al.N Engl J Med. 2021; 385: 1372-1381Crossref PubMed Scopus (65) Google Scholar To address unresolved clinical questions, randomized controlled trials including ours (NCT05043415, NCT05252897, and NCT05451901) are ongoing to explore the optimal timing of step-up treatment in the setting of endotherapy for WON. However, these trials have been designed to investigate a specific step-up timing based on the one-size-fits-all approach, but not the specific algorithm for personalized treatment strategies. In the current study by a leading group in the United States, researchers examined their original protocol requiring step-up treatment for WON lesions with a size reduction of less than 50% for 2 weeks and showed that the protocol-based approach was associated with shorter times to WON resolution and intensive care unit discharge, with a lower rate of adverse events, compared with the on-demand approach. Their findings of a shorter time to WON resolution are plausible because the disease potentially diminishes in size more efficiently through the interventions than spontaneously. Of note, the use of their algorithm was associated with a lower rate of adverse events (42% compared with 72% in the on-demand strategy). Patients treated based on the algorithm-based approach had no severe bleeding events and no perforation, which have been of concern with premature interventions. In contrast, a fraction of patients treated in an on-demand fashion underwent bleeding related to the prolonged placement of a lumen-apposing metal stent (LAMS).5Brimhall B. et al.Clin Gastroenterol Hepatol. 2018; 16: 1521-1528Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar In addition, the number of endoscopic interventions and necrosectomies were similar between the groups. These findings suggest that the advent of LAMS has ensured the safety and effectiveness of early intensive interventions for select patients with WON. Given the evidence suggesting an increased risk of LAMS-related adverse events resulting from prolonged placement (>4 weeks),6Bang J.Y. et al.Gut. 2020; 69: 1379-1381Crossref PubMed Scopus (26) Google Scholar it is considered reasonable to initiate step-up interventions for refractory cases within approximately 2 weeks of the initial drainage. Despite the promising results, some issues should be addressed before the proposed algorithm is applied to WON patients in clinical practice. First, standardized criteria for the size calculation of WON should be defined. To date, the maximum diameter of the largest lesion has been used most commonly in this setting. Three-dimensional volume may have more relevance than the maximum diameter or the 2-dimensional area, but is difficult to estimate manually.7Wang P.F. et al.World J Gastroenterol. 2018; 24: 1911-1918Crossref PubMed Scopus (4) Google Scholar An artificial intelligence–based platform may facilitate 3-dimensional volumetry and thereby provide better estimates of size in the context of the requirement of step-up treatment. In addition, the cut-off point of 50% for size reduction may have different implications for WON lesions with different sizes: eg, 30 cm to 15 cm (which rarely occurs in 2 weeks) vs 10 cm to 5 cm. Therefore, we commend Baroud et al1Baroud S. et al.Clin Gastroenterol Hepatol. 2023; (in press)PubMed Google Scholar for providing the results on the effectiveness of their algorithm according to WON size. Second, step-up treatment may be indicated for reasons other than insufficient size reduction. Therefore, prospective data are required to examine the overall outcomes of the algorithm applied for all WON lesions requiring interventions. Last but not least, given that the high-level expertise of the endoscopists at a high-volume center might contribute to the low rate of adverse events in the early treatment,8Hamada T. et al.Gastrointest Endosc. 2023; (in press)Google Scholar a multicenter study is desirable to validate the effectiveness of the newly designed algorithm in different settings. In summary, along with upcoming results of randomized trials, the current study can help optimize the strategies of endoscopic treatment of symptomatic WON. We thank Baroud et al1Baroud S. et al.Clin Gastroenterol Hepatol. 2023; (in press)PubMed Google Scholar for providing us with valuable data that help advance clinical research in this field. The authors appreciate the following members of the WONDERFUL (WON and peripancreatic fluid collection) study group for their valuable comments on the manuscript: Tomotaka Saito, Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Atsuhiro Masuda, Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan; Mamoru Takenaka, Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan; Hideyuki Shiomi, Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Hyogo, Japan; Hiroyuki Isayama, Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan; Takuji Iwashita, First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan; and Ichiro Yasuda, Third Department of Internal Medicine, University of Toyama, Toyama, Japan." @default.
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• W4380204601 date "2023-06-01" @default.
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• W4380204601 title "Beyond One-Size-Fits-All: Size-Oriented Criteria for the Step-Up Treatment of Walled-Off Pancreatic Necrosis" @default.
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• W4380204601 doi "https://doi.org/10.1016/j.cgh.2023.05.026" @default.
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