Top-down versus step-up approach after endoscopic ultrasound-guided drainage of infected walled-off necrosis: a randomized controlled trial - PubMed

6 hours ago

The study compared two approaches after EUS-guided drainage for infected walled-off necrosis (WON) with >30% solid debris: a top-down strategy with immediate and repeated direct endoscopic necrosectomy (DEN) versus a step-up strategy with DEN only if predefined criteria were met.
The top-down approach resulted in fewer reinterventions (median 1 vs. 2, P=0.02), shorter hospital stays (4 vs. 12 days, P<0.001), and lower readmission rates (18.5% vs. 44.4%, P=0.04) compared to the step-up approach.
No significant differences were found between the groups in terms of the number of DENs, overall procedure burden, new-onset organ failure, procedure-related adverse events (both 7.4%), or all-cause mortality (11.1% vs. 18.5%, P=0.70).
The conclusion suggests that the top-down strategy may lead to better outcomes regarding hospitalization and readmissions without increasing the procedural burden, though readmissions could be influenced by other strategy-related factors.

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