Su1394 Direct Endoscopic Necrosectomy Versus Percutaneous Catheter Drainage for Management of Walled-off Pancreatic Necrosis: A Retrospective Cohort Study

Abstract

Direct Endoscopic Necrosectomy Versus Percutaneous Catheter Drainage for Management of Walled-off Pancreatic Necrosis: A Retrospective Cohort Study Nitin Kumar*, Inbar S. Spofford, Darwin Conwell, Christopher C. Thompson Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA; Pediatric Gastroenterology, Hepatology and Nutrition, Massachusetts General Hospital, Boston, MA Background: There are several management options for walled-off pancreatic necrosis; utilization varies depending on local expertise. The relative effectiveness of initial direct endoscopic necrosectomy (DEN) versus percutaneous catheter drainage (PCD) is not known.Aim: To compare outcome of DEN with PCD for initial management of symptomatic walled-off pancreatic necrosis (WOPN). Methods: Retrospective record review was conducted to identify patients who required debridement of symptomatic necrotic collections. Consecutive patients undergoing DEN or PCD at a tertiary referral center were included. The SAS random number generator was used to select 25 patients from each group for analysis. Patients who did not have walled-off collections, had pseudocyst, were not candidates for endoscopic or percutaneous drainage, or had less than 6 months of follow-up were then excluded. Clinical success was defined as resolution of symptoms without need for further procedural intervention. Outcomes included length of stay (LOS), recurrence, radiologic findings, complication rate, and mortality. Preprocedure collection size was determined using CT within 5 days prior to procedure. Means were compared with Student’s t-test and proportional comparison between groups was performed with Fisher’s Exact test. All statistics are reported as mean SEM. Results: 19 patients with DEN and 21 patients with PCD met criteria for evaluation. Baseline characteristics are summarized in Table 1. Illness severity by APACHE II and Charlson Comorbidity Index were similar between groups. DEN required 1.79 0.2 endoscopies, while PCD required 1.86 0.17 catheter placements (p 0.81). 12/19 DEN patients achieved radiologic resolution versus 3/21 PCD patients. 16/19 DEN patients achieved clinical success with DEN alone versus 4/21 PCD patients undergoing PCD alone (p 0.001). 3/19 DEN patients proceeded to PCD and subsequently improved. 15/21 PCD patients proceeded to surgical necrosectomy after 3.2 0.8 weeks, and 2/21 proceeded to DEN after 2 and 52 weeks. ICU LOS was 0.1 0.1 days after DEN versus 7.9 3.7 days after PCD (p 0.05); floor LOS was 5.4 1.3 days after DEN versus 9.7 1.9 days after PCD (p 0.04). Complications, defined as bleeding, fistula, wound infection, and thromboembolism, occurred in 3/19 after DEN vs 2/21 after PCD (p 0.65). Recurrence of WOPN occurred 3/16 DEN patients who had DEN alone vs 2/6 PCD patients who had PCD alone (p 0.58). Conclusions: Patients with WOPN and similar baseline characteristics who underwent DEN had significantly less rate of progression to surgical necrosectomy than those who underwent PCD. Complication and recurrence rates were similar. Primary DEN may offer more expedient and definitive resolution of WOPN than primary PCD and should be considered first-line therapy.