Endoscopic drainage of walled-off pancreatic necrosis: is necrosectomy and delayed drainage necessary?

Abstract

Introduction: While studies have suggested that endoscopic step up approach with delayed drainage (more than 28 days from symptom onset) produce the best outcome in the treatment of walled-off pancreatic necrosis (WOPN), we assessed our single centre experience with endoscopic drainage of WOPN, in particular, the necessity of necrosectomy and delayed drainage. Methods: Patients who underwent endoscopic drainage for WOPN between October 2011 and June 2019 in Monash Health were identified. They were excluded if follow up data were missing. The included patients' medical records, pathology results, imaging findings and procedure reports were retrospectively reviewed. The outcomes were then compared between early drainage (within 28 days of symptom onset) and delayed drainage cohorts. Results: 38 patients were included for analysis. The population underwent an average of 2.45 endoscopic drainages per patient with none requiring endoscopic necrosectomy. 31.58%% of patients required percutaneous drainage for distant collections and 2 patients received surgical necrosectomy. A disease related mortality of 15.8% and an average length of stay (LOS) of 75.71 days were reported. No statistically significant difference was shown in disease -related mortality (27.3% vs. 11.1%, p = 0.215) or LOS (90.9 vs 69.5, p=0.2905) between early and delayed drainage cohorts, but patients who received early drainage were more unwell at day 18 of symptom onset (qDOFA score 1 vs. 0.3, p= 0.033). Conclusion: Endoscopic drainage in combination with selective percutaneous drainage is effective in the management of walled-off pancreatic necrosis. Early drainage should be considered for patient who remained unstable despite conservative management.