S19 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

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 WOPN and compared it with upfront direct endoscopic necrosectomy. 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% CI for our outcomes of interest. For comparative outcomes, we calculated pooled odds ratios with 95% 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% respectively. Pooled rates (95% CI) of adverse events of SUA were 19.4% (10.9%, 32%), P = 0, I² = 89%. Comparative analysis revealed no significant difference in clinical success between SUA and direct endoscopic necrosectomy 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. Conclusion: 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.