P0012 - Safety and Efficacy of the Endoscopic Step-Up Approach for Walled-Off Pancreatic Necrosis, and Comparison With Upfront Direct Endoscopic Necrosectomy: A Systematic Review and Meta-Analysis

Aamir Saeed, MD¹, Anum Khakwani, MD², Abdul Wasay, MD³, Hina Akbar, MD⁴, Ahmad Zain, MBBS⁵, Saira Yousuf, MD¹, Abdul Mateen, MBBS⁶, Muhammad Kamal, MD⁷, Muhammad Haseeb, MD⁸, Janak Shah, MD⁹, Mark Radlinski, MD¹, Umar Hayat, MD¹⁰, Nasir Saleem, MD¹¹, Faisal Kamal, MD¹²
1Vanderbilt University Medical Center, Nashville, TN; 2Charleston Area Medical Center, Charleston, WV; 3University of Tennessee, Knoxville, TN; 4King Edward Medical University, Chattanooga, TN; 5Parkview Medical Center, Pueblo, CO; 6Services Institute of Medical Sciences, Lahore, Punjab, Pakistan; 7Hackensack Meridian Health, Edison, NJ; 8University of Pittsburgh Medical Center, Pittsburgh, PA; 9Ochsner Health System, New Orleans, LA; 10Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA; 11Indiana University School of Medicine, Indianapolis, IN; 12Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA

Introduction: The endoscopic step-up approach (SUA) is widely used as the preferred treatment for complicated or symptomatic walled-off pancreatic necrosis (WOPN). In this meta-analysis, we have evaluated the efficacy and safety of the endoscopic step-up approach for WON and compared it with upfront direct endoscopic necrosectomy (DEN).

Methods: We reviewed several databases from inception to March 10, 2025, to identify studies

that evaluated the efficacy and safety of the endoscopic step-up approach for WOPN. Our outcomes of interest were technical success, clinical success, and procedure-related adverse events. We calculated pooled rates with 95% confidence intervals (CI) for our outcomes of interest. For comparative outcomes, we calculated pooled odds ratios (OR) with 95% confidence intervals (CI). Data was analyzed using random-effects model. Heterogeneity was assessed using I² statistic.

Results: We included 10 studies with 1040 patients in our final analysis. Pooled rates (95% CI) of technical success and clinical success of SUA were 99% (98.1%, 99.4%), p=1.0, I² =0% and 91% (83%, 95%), p=0, I² =85% (Figure 1A) respectively. Pooled rates (95% CI) of adverse events of SUA were 19.4% (10.9%, 32%), p=0, I² =89% (Figure 1B).



Comparative analysis revealed no significant difference in clinical success between SUA and DEN groups, RR (95% CI): 1.91(0.24, 14.86), P=0.54 . However, rates of procedure-related adverse events were significantly lower in SUA group, RR (95% CI), 0.30(0.09, 0.98), P=0.05.

Discussion: Our study demonstrates the safety and efficacy of the endoscopic step-up approach for walled-off pancreatic necrosis. Large scale randomized controlled studies comparing step-up approach and direct endoscopic necrosectomy are needed to further evaluate these findings.


Figure: Rate of clinical success and adverse events of step up approach


Figure: Comparison of clinical success and adverse events between groups

Disclosures:
Aamir Saeed indicated no relevant financial relationships.
Anum Khakwani indicated no relevant financial relationships.
Abdul Wasay indicated no relevant financial relationships.
Hina Akbar indicated no relevant financial relationships.
Ahmad Zain indicated no relevant financial relationships.
Saira Yousuf indicated no relevant financial relationships.
Abdul Mateen indicated no relevant financial relationships.
Muhammad Kamal indicated no relevant financial relationships.
Muhammad Haseeb indicated no relevant financial relationships.
Janak Shah indicated no relevant financial relationships.
Mark Radlinski indicated no relevant financial relationships.
Umar Hayat indicated no relevant financial relationships.
Nasir Saleem indicated no relevant financial relationships.
Faisal Kamal indicated no relevant financial relationships.

Aamir Saeed, MD¹, Anum Khakwani, MD², Abdul Wasay, MD³, Hina Akbar, MD⁴, Ahmad Zain, MBBS⁵, Saira Yousuf, MD¹, Abdul Mateen, MBBS⁶, Muhammad Kamal, MD⁷, Muhammad Haseeb, MD⁸, Janak Shah, MD⁹, Mark Radlinski, MD¹, Umar Hayat, MD¹⁰, Nasir Saleem, MD¹¹, Faisal Kamal, MD¹². P0012 - Safety and Efficacy of the Endoscopic Step-Up Approach for Walled-Off Pancreatic Necrosis, and Comparison With Upfront Direct Endoscopic Necrosectomy: A Systematic Review and Meta-Analysis, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.