The Management of Walled off Pancreatic Necrosis in 2023 – Lessons Learned From the Past Two Decades

Abstract

Acute necrotizing pancreatitis is associated with the formation of acute necrotic collection which eventually becomes encapsulated to form walled-off pancreatic necrosis (WOPN) in 4 weeks. Good quality randomized controlled trials published in the past two decades have helped us understand and refine the management of WOPN. This review summarizes the lessons learned from these trials. Sterile pancreatic necrosis is managed conservatively unless they cause symptoms. Infected pancreatic necrosis leads to organ failure and mortality. The treatment paradigm for infected pancreatic necrosis has shifted from early open necrosectomy to initial intensive medical management, followed by interventions. Step-up approach with initial drainage followed by minimally invasive necrosectomy, in selected patients who do not improve with drainage, has been shown to have better short-term and long-term outcomes. Endoscopic step-up approach has been associated with a lower incidence of pancreaticocutaneous fistula and similar mortality or organ failure as compared to surgical step-up approach. Dedicated endoscopic accessories for performing necrosectomy are undergoing validation studies, which hopefully will help perform necrosectomy with less complications.