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We thank Tiwari et al1Tiwari et al.Gastroenterology. 2023; 164: 496-497Abstract Full Text Full Text PDF Scopus (1) Google Scholar for their letter regarding the recently published ExTENSION trial and would like to respond to the addressed points.1.The minimally invasive surgical stepup approach indeed starts with percutaneous catheter drainage, only followed by video-assisted retroperitoneal debridement when a patient clinically deteriorates. We, and other previous randomized controlled trials, used this definition as well, so we chose to remain consistent.2van Brunschot S. et al.Lancet. 2018; 391: 51-58Abstract Full Text Full Text PDF PubMed Scopus (334) Google Scholar,3van Santvoort H.C. et al.N Engl J Med. 2010; 362: 1491-1502Crossref PubMed Scopus (1011) Google Scholar2.It is correct that although not statistically significant, the median overall length of hospital stay was shorter in the endoscopy group. However, after the initial 6-month follow-up, most hospital admissions were not related to pancreatitis. During the initial 6-month follow-up of the TENSION trial, the hospital stay did differ in favor of the endoscopy group.3.All pancreaticocutaneous fistulas mentioned in our study occurred or persisted for at least 6 months after infected necrotizing pancreatitis. These fistulas were all considered as complex and were therefore not expected to close spontaneously within 3 months.4.We provided more details on the etiology and treatment of recurrent acute pancreatitis according to the revised Atlanta criteria in the supplementary apendix.4Banks P.A. et al.Gut. 2013; 62: 102-111Crossref PubMed Scopus (3563) Google Scholar All cases of recurrent acute pancreatitis occurred as separate episodes with resolution of symptoms between episodes.5Romagnuolo J. et al.Gastrointest Endosc. 2008; 68: 966-974Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Of note, except for 1 patient, all patients did not have a drain in situ at the time of diagnosis of recurrent acute pancreatitis.5.Because radiologic imaging was not routinely performed during long-term follow-up, asymptomatic disrupted or disconnected ducts (DPDSs) may have been missed, especially in patients with transluminal plastic stents in situ after endoscopic drainage. Although the consequences of DPDSs differed between the groups, we do not expect that the presence of a DPDS is influenced by either approach.6.The extent of pancreatic necrosis was assessed by computed tomography (CT) scans and CT severity scores, and described in the original TENSION trial and supplementary appendix.2van Brunschot S. et al.Lancet. 2018; 391: 51-58Abstract Full Text Full Text PDF PubMed Scopus (334) Google Scholar The extent of necrosis did not differ between the endoscopic and surgical stepup approach.7.The ExTENSION trial focused on the long-term clinical outcomes of the TENSION trial after the endoscopic or surgical stepup approach. The timing of the initial intervention was therefore not the subject of investigation. TENSION Trial to ExTENSION Study: Has Extension Decreased Tension?GastroenterologyVol. 164Issue 3PreviewWe read with interest a recently published study titled “Endoscopic Versus Surgical Step-Up Approach for Infected Necrotizing Pancreatitis (ExTENSION): Long-term Follow-up of a Randomized Trial,”1 a first-of-its-kind long-term prospective follow-up of a landmark multicenter randomized controlled trial (the TENSION trial) evaluating the role of an endoscopic step-up approach with respect to surgery in infected pancreatic walled off necrosis (WON). Full-Text PDF