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Related Concept Videos

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Endoscopic Retrograde Cholangiopancreatography (ERCP) is a diagnostic procedure that combines endoscopy and fluoroscopy to diagnose and treat conditions related to the bile ducts, pancreatic ducts, and gallbladder. This procedure is beneficial for identifying and addressing blockages, gallstones, strictures, and tumors within the biliary or pancreatic systems. ERCP is both diagnostic and therapeutic, offering the ability to visualize and treat identified problems in one session.
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Updated: Sep 10, 2025

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Endoscopic Step-up Approach for Walled-off Necrosis After Acute Pancreatitis.

Shuntaro Mukai1, Atsushi Sofuni1, Takayoshi Tsuchiya1

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|August 27, 2025
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Summary

Minimally invasive endoscopic treatments, including endoscopic ultrasound-guided drainage and endoscopic necrosectomy with lumen-apposing metal stents (LAMSs), offer effective options for symptomatic walled-off necrosis (WON) after pancreatitis.

Keywords:
endoscopic necrosectomyendoscopic ultrasound‐guided pancreatic fluid collection drainagelumen‐apposing metal stentstep‐up approachwalled‐off necrosis

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Area of Science:

  • Gastroenterology
  • Interventional Endoscopy
  • Pancreatic Diseases

Background:

  • Late mortality from necrotizing pancreatitis, particularly infected necrosis, remains a significant clinical challenge.
  • Symptomatic walled-off necrosis (WON) necessitates invasive intervention, often requiring a step-up treatment strategy.
  • Minimally invasive approaches are preferred initially, escalating to more invasive methods if initial treatments are insufficient.

Purpose of the Study:

  • To review current interventional strategies for managing symptomatic walled-off necrosis (WON).
  • To evaluate the efficacy and limitations of endoscopic approaches in treating WON.
  • To discuss the role of lumen-apposing metal stents (LAMSs) and newer endoscopic techniques.

Main Methods:

  • Review of current literature on interventional strategies for symptomatic WON.
  • Focus on endoscopic step-up approaches, including endoscopic ultrasound-guided drainage and endoscopic necrosectomy (EN).
  • Discussion of lumen-apposing metal stents (LAMSs), multiple transluminal gateways, and transcystic drainage techniques.

Main Results:

  • Endoscopic step-up approaches, particularly transmural treatment with endoscopic ultrasound-guided drainage and EN using LAMSs, demonstrate favorable outcomes.
  • LAMSs enhance drainage and facilitate EN, but bleeding and stent-related adverse events are potential concerns.
  • Advanced techniques like multiple transluminal gateways and transcystic drainage improve outcomes for complex WON cases.

Conclusions:

  • Endoscopic therapy alone, utilizing LAMSs and advanced drainage techniques, can successfully treat most WON cases.
  • Endoscopic treatment has limitations for pelvic cavity involvement, necessitating consideration of combined percutaneous or surgical approaches.
  • The step-up approach, prioritizing minimally invasive endoscopic interventions, is the recommended strategy for symptomatic WON.