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SAGES systematic review and meta-analysis for the management of symptomatic walled-off pancreatic necrosis
Olivia Ganescu1, Elisa C Calabrese2,3,4,5, Himsikhar Khataniar6
1Division of General Surgery, McGill University Health Centre, Montreal, QC, Canada.
Background:
Optimal management of symptomatic walled-off pancreatic necrosis (WOPN) continues to evolve, yet current guidelines provide limited direction across treatment options. This systematic review and meta-analysis compared WOPN interventions to inform forthcoming clinical guidelines by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).
Methods:
A systematic review through January 24, 2025, addressed four key questions (KQs): (1) image-guided versus endoscopic, (2) image-guided versus surgical, (3) endoscopic versus surgical, and (4) pure endoscopic versus the step-up approaches. Randomized controlled trials (RCTs) and comparative observational studies were included. Meta-analyses used random-effects models. Certainty of evidence (CoE) was assessed using GRADE. Reporting followed PRISMA 2020.
Results:
Compared to endoscopic (KQ1), image-guided intervention may be associated with higher mortality (OR: 4.80), increased combined and surgical reintervention (OR: 3.94), more severe complications (OR: 5.42), and longer hospital stay (OR: 15.75). Compared to open surgery (KQ2), image-guided intervention may be associated with lower mortality (OR: 0.40) and fewer radiologic reinterventions (OR: 0.14), but higher surgical reintervention (OR: 4.28). No significant differences were observed compared with minimally invasive surgery (MIS). In RCT data, endoscopic and MIS approaches (KQ3) may have similar outcomes, with no significant differences in mortality, complications, or reintervention. For pure endoscopic vs step-up approaches (KQ4), RCT data suggest that an endoscopic-only strategy may be associated with fewer severe complications (OR: 0.36) but higher rates of radiologic (OR: 4.48) and endoscopic reinterventions (OR: 2.96), with no clear difference in mortality.
Conclusion:
Endoscopic management may be associated with more favorable outcomes than image-guided interventions. Image-guided intervention may be associated with lower mortality than open surgery but increased surgical reintervention. Endoscopic and MIS approaches may be equally effective. Endoscopic-only approaches may reduce severe complications at the cost of more reinterventions than the step-up approach. Overall, CoE is very low, highlighting the need for high-quality, multicenter RCTs.
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