Abstract Background Acute infected necrotizing pancreatitis remains associated with substantial morbidity and mortality. The step-up approach combining minimally invasive drainage with endoscopic transgastric or percutaneous necrosectomy, improves outcomes compared with open surgery. Laparoscopic-assisted necrosectomy (LAPN) may be performed in cases of superinfected walled-off necrosis (WON) following percutaneous drainage. A newly implemented interdisciplinary approach includes sinus tract endoscopy–guided necrosectomy (STEN), using flexible endoscopy through a surgically created sinus tract, enabling less invasive, more targeted debridment, improved visualization of complex necrotic cavities, and facilitating repeatable debridement. Aims This study aimed to assess the introduction of STEN compared with LAPN in the management of superinfected WON. Methods A retrospective analysis of patients with superinfected WON treated with a percutaneous step-up approach between 2019 and 2025 was conducted. Patients underwent CT-guided percutaneous drainage followed by either STEN or LAPN. Demographic characteristics and clinical outcomes were collected. The primary endpoint was the non-inferiority of STEN compared with LAPN, assessed using a composite outcome comprising major complications and 6-month mortality. Secondary outcomes included overall complication rates, need for reinterventions, and length of hospital stay. Results Fifteen patients were included. All patients were managed using a step-up approach: 9 underwent STEN and 6 underwent LAPN. In the STEN group, 5 patients (55.6%) met the primary endpoint, all due to major complications, with no mortality observed. In the LAPN group, the primary endpoint occurred in 3 patients (50%), including one death and two major complications. The difference in the composite outcome remained well below the predefined 15% non-inferiority margin, confirming the non-inferiority of STEN compared with standard LAPN. Conclusion Both STEN and LAPN are effective in treating superinfected WON within a step-up approach. Despite the limited sample size, STEN achieved non-inferior outcomes compared with LAPN. Larger prospective studies are warranted to further define the role of STEN in the management of infected WON.
Kremo et al. (Mon,) studied this question.