Factors Impacting Treatment Outcomes in the Endoscopic Management of Walled-off Pancreatic Necrosis

Ji Young Bang; C Mel Wilcox; Jessica Trevino; Jayapal Ramesh; Shajan Peter; Muhammad Hasan; Robert H. Hawes; Shyam Varadarajulu

Disclosures

J Gastroenterol Hepatol. 2013;28(11):1725-1732. 

In This Article

Abstract and Introduction

Abstract

Background Treatment outcomes are suboptimal for patients undergoing endoscopic treatment of walled-off pancreatic necrosis (WOPN). The objective of this study is to identify factors that impact treatment outcomes in this patient subset.

Methods This is a retrospective study of patients with WOPN treated endoscopically over 10 years. Patients underwent placement of stents and nasocystic catheters within the necrotic cavity. In select patients, the multiple transluminal gateway technique (MTGT) was adopted to create several openings in the stomach or duodenum to facilitate drainage of necrosis. In patients with disconnected pancreatic duct syndrome (DPDS), the transmural stents were left in place indefinitely to decrease pancreatic fluid collection (PFC) recurrence.

Results Endoscopic treatment was successful in 53 of 76 (69.7%) patients. Treatment success was higher in patients undergoing MTGT than in those in whom conventional drainage was used (94.4% vs 62.1%, P = 0.009). On multivariate logistic regression analysis, only MTGT (OR 15.8, 95% CI 1.77–140.8; P = 0.01) and fewer endoscopic sessions being needed (OR 4.0, 95% CI 1.16–14.0; P = 0.03) predicted treatment success. PFC recurrence was significantly lower in patients with indwelling transmural stents than in patients in whom the stents were removed (0 vs 20.8%; P = 0.02).

Conclusions Creating multiple gateways for drainage of necrotic debris improves treatment success, and not removing the transmural stents decreases PFC recurrence in patients undergoing endoscopic drainage of WOPN.

Introduction

Walled-off pancreatic necrosis (WOPN) is characterized by a distinct rim that forms around the necrosis and adjacent pancreatic parenchyma.[1] Most WOPNs are sterile and can be managed conservatively without any intervention.[2–4] Indications for interventions include ongoing infection despite administration of antibiotics and continued clinical deterioration despite supportive measures.[5] Although the traditional treatment approach used to be open necrosectomy to completely remove the necrosis, this is an invasive option associated with a high risk of complications (30–94%), mortality (11–39%), and long-term pancreatic insufficiency.[6–8]

As an alternative to open necrosectomy, minimally invasive endoscopic and radiological techniques have gained acceptance.[5] In endoscopic drainage, the WOPN is identified by a visible luminal compression or by using endoscopic ultrasound (EUS) guidance. Following puncture, the transmural tract is dilated, and double pigtail stents and nasocystic drainage catheters are placed to drain the necrotic contents. Retrospective studies have shown a treatment success rate of 45–63% for endoscopic drainage.[9,10] In patients with no clinical improvement despite transmural drainage, endoscopic necrosectomy or surgery can be undertaken to remove the necrotic debris. In a recent review of 10 series on endoscopic necrosectomy, the overall treatment success was 76%, mortality 5%, and procedure-related morbidity 27%.[11] Major limitations of endoscopic necrosectomy are that the procedure is labor intensive and requires greater technical expertise and that the procedure-related adverse events are not insignificant.[9,12] Therefore, developing techniques that improve the treatment success of endoscopic transmural drainage is important.

Despite initial treatment success, a significant proportion of patients with WOPN develop recurrent pancreatic fluid collections (PFCs) due to disconnected pancreatic duct syndrome (DPDS).[13,14] Therefore, techniques for minimizing long-term PFC recurrence are important treatment strategies that need development.

The objective of the present study is to identify factors that impact treatment outcomes in patients undergoing endoscopic transmural drainage of WOPN, particularly to improve treatment success and decrease PFC recurrence.

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