An accelerated treatment approach may save lives in pancreatic walled-off necrosis

An accelerated treatment algorithm appeared to benefit patients with large pancreatic walled-off necrosis (WON) in terms of length-of-stay in the hospital and major complications compared with the standard endoscopic step-up approach, according to interim results of the ACCELERATE trial.

“We hypothesised that an accelerated treatment algorithm may shorten the duration of hospitalisation and possibly reduce morbidity and mortality in patients who are treated for large WON, if this approach is compared with the classical step-up approach,” said Dr Gitte Olsen (Copenhagen University Hospital, Denmark) [1]. To test this hypothesis, the investigators designed the single-centre, open-label, randomised ACCELERATE trial. The primary endpoint was a composite of death, major complications (i.e. organ failure, bleeding requiring intervention, perforation of visceral organ or enterocutaneous fistula requiring intervention), and a length of stay of ≥58 days.

Enrolled were 48 adult participants with symptomatic or infected pancreatic WON ≥15 cm, who were randomised 1:1 to the accelerated approach or conventional step-up treatment. All participants underwent trans-gastric drainage with a 20 mm lumen-apposing metal stent. In the accelerated group, an immediate endoscopic necrosectomy was performed in the same session and was continued as needed until the WON cavity was cleared of necrotic tissue. In the step-up arm, further drainage or necrosectomy was only performed if the clinical condition had not improved after 72 hours.

The current interim analysis included 25 participants. Only 8.3% of the participants in the experimental arm had a primary outcome event, compared with 61.5% of the participants in the control arm (P=0.011). The effect was mainly driven by a length of stay ≥58 days (8.3% vs 53.8%; P=0.027) but also by major complications (0.0% vs 46.2%; P=0.015). “After seeing these results, the study was terminated for safety reasons,” mentioned Dr Olsen. Finally, Dr Olsen noted that the mean length of stay in the hospital was only 32.5 days in the experimental arm and 68.5 days in the control arm (P=0.039).

“Although the sample size of the study was small, it appears that an accelerated treatment algorithm reduces major complications and length of stay in the hospital in patients with large WON,” decided Dr Olsen.

1. 
   
   1. Olsen GA, et al. Accelerated vs step-up endoscopic treatment for large pancreatic walled-off necrosis: Interim analysis of a single-center randomized trial (ACCELERATE trial). LB16, UEG Week 2024, 12–15 October, Vienna, Austria.

Medical writing support was provided by Robert van den Heuvel.
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Posted on 17 October 2024