Elisa C Calabrese, Dena Shehata, Bethany J Slater, Francesco Palazzo, Adnan Alseidi, James Sun, Edwin Onkendi, David Caba Molina, Katlin Mallette, Ansley B Ricker, Subhashini Ayloo, Joshua Lyons, Guy Maddern, Rodolfo J Oviedo, Muhammed Elhadi, Ali Kchaou, Saamia Shaikh, Felipe B Maegawa, Andrew Catanzaro, Richard D Shlansky-Goldberg, Sean Cleary, Ivan D Florez, Kevin El-Hayek
Current evidence evaluating FLIP in surgical practice is limited and, largely, of very low certainty, but FLIP shows potential as a complementary diagnostic and intraoperative tool in foregut disorders. These recommendations provide an initial framework for the responsible, evidence-informed use of this technology in clinical practice. Further prospective studies are essential to establish standardized protocols, define clinically meaningful thresholds, and strengthen future guideline updates in adult and pediatric populations.
BACKGROUND: Walled-off pancreatic necrosis (WOPN) is a serious sequela following acute pancreatitis with significant associated morbidity and mortality. These guidelines provide best practice recommendations for the management of this complication.
METHODOLOGY: A systematic review was conducted, including a literature search from 1/1/2020 to 1/24/2025, addressing four key questions regarding the management of WOPN in adults. The findings were subsequently presented to a multidisciplinary panel of surgeons, gastroenterologists, and interventional radiologists, including those from both the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the Americas Hepato-Pancreato-Biliary Association (AHPBA). The GRADE methodology was then used to develop evidence-based recommendations.
RESULTS: All recommendations were based on very low certainty of evidence. A conditional recommendation was made for endoscopic management versus image-guided intervention. A conditional recommendation was made for image-guided intervention versus open surgery. A conditional recommendation was made for either minimally invasive surgery or image-guided intervention. A conditional recommendation was made for minimally invasive surgery versus endoscopic intervention. A conditional recommendation was made for either a pure endoscopic approach versus a step-up approach.
CONCLUSIONS: These recommendations provide guidance for the approach to the management of WOPN according to the existing literature and expert input. The panel also highlighted evidence gaps to support future research for a stronger evidence base regarding the treatment of WOPN.