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

An accelerated treatment algorithm may benefit patients with large pancreatic walled-off necrosis (WON) by reducing hospital length of stay 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 pancreatic WON compared with the classical step-up approach,” said Dr Gitte Olsen (Copenhagen University Hospital, Denmark) [1]. The investigators designed the single-centre, open-label, randomised ACCELERATE trial to test this hypothesis. 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 hospital stay of ≥58 days.

The study enrolled 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, additional 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 accelerated arm experienced a primary outcome event, compared with 61.5% in the control arm (P=0.011). The effect was mainly driven by a reduced length of stay ≥58 days (8.3% vs 53.8%; P=0.027) but also by a lower rate of major complications (0% vs 46.2%; P=0.015). Bleeding was the most frequent complication in the classical step-up treatment, followed by enterocutaneous fistulas. “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 significantly shorter in the accelerated arm than in the control (32.5 vs 68.5 days; P=0.039).

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

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Posted on 28 November 2024