Interdisciplinary Step-Up Strategy for Infected Pancreatic Walled-Off Necrosis: Sinus Tract Endoscopic Necrosectomy (STEN) Versus Laparoscopic-Assisted Necrosectomy (LAPN)

Background/Objectives: Acute infected necrotizing pancreatitis remains associated with substantial morbidity and mortality. The step-up approach combines minimal-invasive drainage with endoscopic transgastric or percutaneous necrosectomy and has been shown to improve outcomes compared with open surgery. Laparoscopic-assisted necrosectomy (LAPN) may be performed in cases of infected walled-off necrosis (WON) following percutaneous drainage and is typically carried out using laparoscopic instrumentation. A newly implemented interdisciplinary approach includes sinus tract endoscopy, guided necrosectomy (STEN), which employs flexible endoscopy through a surgically created sinus tract and offers a less invasive and more targeted alternative to LAPN, providing improved visualization of complex necrotic cavities and facilitating repeatable step-up debridement. This study aimed to assess the introduction of STEN compared with LAPN in the management of infected WON within a step-up approach. Methods: A retrospective analysis of patients with infected walled-off necrosis (WON) treated using a step-up approach between 2019 and 2025 was conducted. Patients who underwent CT-guided percutaneous drainage followed by either STEN or LAPN were included. Demographic characteristics and clinical outcomes were collected. The primary endpoint was a composite outcome comprising major complications and 6-month mortality. Secondary outcomes included overall complication rates, need for reinterventions, and length of hospital stay. Results: During the study period, 17 patients were included. All patients were managed using a step-up approach: nine underwent STEN and eight underwent LAPN. In the STEN group, six patients (66.7%) met the primary endpoint, all due to major complications, with no mortality observed. In the LAPN group, the primary endpoint occurred in four patients (50.0%), including one death and three major complications. Conclusions: Our study showed that both STEN and LAPN were effective in treating infected WON within a step-up approach. STEN and LAPN showed comparable outcomes. However, these findings should be interpreted as exploratory and with caution given the retrospective design and the small sample size of this study. Further studies with larger patient cohorts are warranted to confirm these findings and to better define the role of this technique in the management of infected necrotizing pancreatitis.