The second shot to walled‐off necrosis: The sooner the better versus sooner or later

Abstract

To the Editor, We read with great interest the article by Pawa et al.,1 reporting a retrospective study comparing immediate and delayed direct endoscopic necrosectomy (DEN) after lumen-apposing metal stent placement for walled-off necrosis. The authors reported preferable outcomes of the delayed DEN in terms of length of stay and the number of DEN sessions as well as comparable rates of clinical success and adverse events. There has been a debate about the optimal timing of DEN during the treatment course of walled-off necrosis.2 The rationale of delaying interventions has been supported by a randomized trial by the Dutch pancreatitis group, which demonstrated the potential of delayed catheter drainage in avoiding a part of adjunctive interventions.3 However, other groups reported conflicting results that a reduction in an interval until the second intervention might be translated into that in the overall treatment duration.4 In the current study, the delayed DEN group consisted of patients presenting with systemic inflammatory response syndrome for whom DEN was postponed for at least 7 days. Since patients with systemic inflammatory response syndrome were generally associated with worse clinical outcomes, we believe that the study results in favor of delayed DEN were promising. Nonetheless, given the time to DEN of more than 7 days in the delayed DEN group, length of stay (reported to be 3 days in this group) might not be a good surrogate of treatment effectiveness. We therefore ask the authors to provide other metrics such as time to clinical success and the rate of avoiding DEN in the delayed group, which would increase the clinical relevance of their findings. In summary, along with upcoming results of randomized trials by our group (NCT05451901) and others, the current study would help us to address clinical unmet needs in endoscopic treatment of symptomatic walled-off necrosis and optimize treatment strategies. The authors would like to appreciate the following members of the WONDERFUL study group for their valuable comments on the manuscript: Tomotaka Saito, Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Mamoru Takenaka, Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan; Hideyuki Shiomi, Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Hyogo, Japan; Hiroyuki Isayama, Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan; Takuji Iwashita, First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan. This work was supported in part by a grant from the Japanese Foundation for Research and Promotion of Endoscopy (#1015 to T. Saito). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors declare that they have no conflicts of interest. Ichiro Yasuda serves as an Associate Editor of DEN Open, and Yousuke Nakai serves as an Associate Editor of Digestive Endoscopy. Japanese Foundation for Research and Promotion of Endoscopy (#1015).