Julia Mühlhäusser

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.

Distal radius and ankle fractures are one of the most common operatively treated fractures. To date, there is no consensus concerning the need for a standard postoperative radiograph. This leads to undesirable practice variations. A standardized radiograph in the department of radiology would theoretically be more reproducible and operator independent than an intraoperatively obtained fluoroscopic image. However, if adequate intraoperative radiographs have been obtained, it is questionable if these postoperative radiographs are necessary and will lead to changes in the treatment strategy. If standard postoperative radiographs are no longer required, this would lead to a reduction in radiation exposure and health care costs. The hypothesis is that routine standardized postoperative radiographs do not influence the quality of care for patients operated on for either a distal radius or an ankle fracture if adequate intraoperative standardized radiographs have been obtained. The primary aim of this study is to evaluate if there is a need for routine postoperative radiographs after an osteosynthesis of a distal radius or ankle fracture. In a prospective, randomized controlled, open label trial based on a noninferiority design, we will enroll 332 patients. Patients will be randomized either in the control or the intervention group. The control group will be treated according to our current, standard protocol in which all patients receive a standard anterior-posterior and lateral radiograph on the first postoperative day. Patients randomized to the intervention group will be treated without a standard postoperative radiograph. All patients (N=332) will have a routine clinical and radiographic control after 6 weeks in the outpatient clinic. Primary outcome is a change in treatment plan, defined as either additional imaging or a reoperation based on the postoperative imaging. Secondary outcome measures include a 36-Item Short Form Survey, Patient-Rated Wrist Hand Evaluation, Foot and Ankle Outcome Score, Visual Analogue Scale, and the range of motion. Those questionnaires will be filled out at the 6-week outpatient control. The trial was started in August 2016, and 104 patients have been enrolled up to this point. Our findings will be reported in peer-reviewed publications and may lead to a strong reduction in radiation exposure and health care costs. A preliminary, conservative estimation suggests a yearly cost saving of CHF 1.3 million in Switzerland.