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However, ETDN may be insufficient in some cases, necessitating adjunctive techniques such as video-assisted retroperitoneal debridement (VARD) or endoscopic ultrasound-guided transcolonic drainage and necrosectomy (EUS-TC). The optimal step-up strategy in these patients remains unclear. We aimed to assess management of WON beyond the reach of ETDN.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Patients with WON undergoing EUS-TC or VARD were identified from a prospectively maintained database between 2017 and 2024.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Forty-five consecutive patients (median age 53\u00a0years; median WON size 24\u00a0cm) were included, with a median follow-up of 19\u00a0months. Thirty-three patients (73%) underwent VARD, and 12 patients (27%) underwent EUS-TC. The median length of stay (LOS) was 85\u00a0days (IQR 48\u2013126) for the VARD group and 74\u00a0days (IQR 40\u2013152) for the EUS-TC group, and did not differ significantly (p\u2009=\u20090.818). In-hospital mortality was 18% (n\u2009=\u20098), all due to organ failure, with no difference between the two groups, p\u2009=\u20090.661. Thirty-seven (82%) patients achieved complete resolution (28 VARD, 9 EUS-TC). Overall, 10 (27%) patients (eight in VARD group and 3 in EUS-TC group, one patient was treated with both VARD and EUS-TC) developed 12 external fistulas (10 enterocutaneous (six colo-cutaneous, four small bowel) and two pancreatico-cutaneous. All pancreatico-cutaneous fistulas were managed conservatively, whereas all six patients with colo-cutaneous fistulas necessitated intervention.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>EUS-TC and VARD are both viable options for managing transgastrically inaccessible WON, although management remains associated with substantial LOS and external fistula formation.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00464-026-12607-w","type":"journal-article","created":{"date-parts":[[2026,2,3]],"date-time":"2026-02-03T20:10:58Z","timestamp":1770149458000},"page":"3202-3209","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Management of walled-off pancreatic necrosis (WON) beyond the conventional step-up strategy: a retrospective cohort study"],"prefix":"10.1007","volume":"40","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4474-4098","authenticated-orcid":false,"given":"Mohamed","family":"Ebrahim","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5824-8207","authenticated-orcid":false,"given":"Morten Laks\u00e1foss","family":"Lauritsen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David Fenger","family":"Schefte","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4453-4624","authenticated-orcid":false,"given":"Gitte Aabye","family":"Olsen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6246-874X","authenticated-orcid":false,"given":"Srdan","family":"Novovic","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9333-0399","authenticated-orcid":false,"given":"John G\u00e1sdal","family":"Karstensen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,2,3]]},"reference":[{"key":"12607_CR1","doi-asserted-by":"publisher","first-page":"1245","DOI":"10.1111\/den.14295","volume":"34","author":"M Ebrahim","year":"2022","unstructured":"Ebrahim M, Werge MP, Hadi A, Lahchich M, Nagras ZG, Lauritsen ML et al (2022) Clinical outcomes following endoscopic or video-assisted retroperitoneal management of acute pancreatitis with large (>15 cm) walled-off pancreatic necrosis: Retrospective, single tertiary center cohort study. 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Mohamed Ebrahim, Morten Laks\u00e1foss Lauritsen, David Fenger Schefte, Gitte Aabye Olsen, and Srdan Novovic have no conflicts of interest to declare.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Disclosure"}}]}}