2937 Endoscopic Ultrasound-Guided Drainage and Treatment of Symptomatic Walled-Off Pancreatic Necrosis: A Single Center Case Series

Abstract

INTRODUCTION: Walled-off pancreatic necrosis (WOPN) develops within 4-6 weeks after acute necrotizing pancreatitis. Endoscopic transgastric pancreatic necrosectomy has emerged as a promising therapy for WOPN. We aim to evaluate the clinical success and outcomes of patients treated with endoscopic therapy for symptomatic WOPN. METHODS: Retrospective chart review of all patients who underwent endoscopic pancreatic necrosectomy from January 2015 until November 2018 was performed. Patients' demographics were obtained including etiology of pancreatitis, size of WON, number of endoscopic necrosectomies, time to resolution of necrosis, and outcome. RESULTS: 15 patients underwent endoscopic necrosectomy for symptomatic WOPN. 60% were male, average age was 56 years. Etiologies of pancreatitis included: Biliary (46%), alcohol induced (20%), hypertriglyceridemia (13%), and idiopathic (20%). Nine (60%) cases presented with infected necrosis diagnosed by cross-sectional imaging and clinical criteria. The Median size of peripancreatic fluid collections was 14 cm (Range: 8-20 cm). Endoscopic necrosectomy was performed through the transgastric route in all patients. All patients underwent initial necrosectomy at time of cystgastrostomy. 13 (87%) patients had luminal apposing stents (LAS) (Axios, Boston Scientific). Axios 15 mm × 10 mm were most common. The mean number of endoscopic therapy sessions was 3.4 (Range 1-8). Two (13%) patients had migrated LAS within 4 weeks. One patient underwent repeat cystgastrostomy to remove an internal migrated stent. There were no reported complications of bleeding, procedure-related infection, or perforation associated with cystgastrostomy or necrosectomy. None of the patients suffered death. Clinical success was achieved in 80% of our patient population defined by resolution of fluid collection and necrosis and clinical improvement. 3 (20%) patients required additional surgical intervention. One required surgical intervention for a pancreatic fluid collection not accessible by the endoscope. One underwent surgery prior to presenting to our center. The third had a large sized necrosis with multiple admission for sepsis and failure to thrive. CONCLUSION: Sequential endoscopic transgastric necrostectomy is a promising therapy for WOPN and should be the first modality to treat patients with infected or symptomatic walled-off necrosis. Large fluid collections, recurrent admissions, failure to thrive, and collections not accessible by the endoscope were indicators for surgical intervention.