Clinical outcome of endoscopic treatment for symptomatic sterile walled-off necrosis

Abstract

Background The majority of patients with symptomatic sterile walled-off necrosis (WON) can be treated conservatively. Although endoscopic transluminal drainage (ETD) is often performed in cases of persistent symptoms, post-procedural iatrogenic infection may occur. This study aimed to evaluate clinical outcomes after ETD of symptomatic sterile WON.

Methods This was a retrospective, multicenter, open-label case series of 56 patients with necrotizing pancreatitis who underwent ETD for symptomatic sterile WON between July 2001 and August 2018 at two tertiary referral hospitals. Primary end point was clinically relevant post-procedural iatrogenic infection, defined as need for endoscopic transluminal necrosectomy. Secondary end points included mortality, total number of interventions, hospital stay, and resolution of symptoms at 1-year follow-up. 

Results ETD of sterile WON was performed in 56 patients (median age 55 years, 57 % male), who presented with abdominal pain (71 %), gastric outlet obstruction (45 %), jaundice (20 %), and failure to thrive (27 %). A total of 41 patients (73 %) developed clinically relevant post-procedural iatrogenic infection, resulting in a median of 3 (interquartile range [IQR] 2 – 4) endoscopic, radiological, and/or surgical interventions. Mortality rate was 2 %. Median total hospital stay was 12 days (IQR 6 – 17). Resolution of symptoms was reported in 40 of 46 patients (87 %) for whom long-term follow-up data were available (median follow-up 13 months, IQR 6 – 29).

Conclusions ETD of symptomatic sterile WON resulted in high clinical success. Nonetheless, the majority of patients required additional reinterventions for clinically relevant post-procedural iatrogenic infection.

Publikationsverlauf

Eingereicht: 04. November 2019

Angenommen: 12. Juni 2020

Accepted Manuscript online:
12. Juni 2020

Artikel online veröffentlicht:
10. Juli 2020

• References

• 1 Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006; 92: 2379-2400
• 2 Banks PA, Bollen TL, Dervenis C. et al. Classification of acute pancreatitis – 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111
• 3 Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13: 1-15
• 4 Wroński M, Cebulski W, Pawłowski W. et al. Walled-off necrosis: safety of watchful waiting. Dig Dis Sci 2015; 60: 1081-1086
• 5 Walser EM, Nealon WH, Marroquin S. et al. Sterile fluid collections in acute pancreatitis: catheter drainage versus simple aspiration. Cardiovasc Intervent Radiol 2006; 29: 102-107
• 6 Zerem E, Imamovic G, Omerović S. et al. Randomized controlled trial on sterile fluid collections management in acute pancreatitis: should they be removed?. Surg Endosc 2009; 23: 2770-2777
• 7 van Brunschot S, van Grinsven J, van Santvoort HC. et al. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391: 51-58
• 8 Khan MA, Kahaleh M, Khan Z. et al. Time for a changing of guard. J Clin Gastroenterol 2019; 53: 81-88
• 9 Bang JY, Arnoletti JY, Holt JP. et al. An endoscopic transluminal approach, compared to minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis. Gastroenterology 2019; 156: 1027-1040.e3
• 10 Khreiss M, Zenati M, Clifford A. et al. Cyst gastrostomy and necrosectomy for the management of sterile walled-off pancreatic necrosis: a comparison of minimally invasive surgical and endoscopic outcomes at a high-volume pancreatic center. J Gastrointest Surg 2015; 19: 1441-1448
• 11 Hartwig W, Werner J, Müller CA. et al. Surgical management of severe pancreatitis including sterile necrosis. J Hepatobiliary Pancreat Surg 2002; 9: 429-435
• 12 Zhang Y, Zhang SY, Gao SL. et al. Successful resolution of gastric outlet obstruction caused by pancreatic pseudocyst or walled-off necrosis after acute pancreatitis the role of percutaneous catheter drainage. Pancreas 2015; 44: 1290-1295
• 13 Karjula H, Nordblad Schmidt P, Mäkelä J. et al. Prophylactic pancreatic duct stenting in severe acute necrotizing pancreatitis: a prospective randomized study. Endoscopy 2019; 51: 1027-1034
• 14 Hyun JJ, Sahar N, Singla A. et al. Outcome of infected versus symptomatic sterile walled-off pancreatic necrosis treated with minimally invasive therapy. Gut Liver 2019; 13: 215-222
• 15 Werge M, Novovic S, Schmidt PN. et al. Infection increases mortality in necrotizing pancreatitis: a systematic review and meta-analysis. Pancreatology 2016; 16: 698-707
• 16 Bang JY, Navaneethan U, Hasan MK. et al. Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomised trial. Gut 2018; 68: 1-10
• 17 Voermans RP, Veldkamp MC, Rauws EA. et al. Endoscopic transmural debridement of symptomatic organized pancreatic necrosis (with videos). Gastrointest Endosc 2007; 66: 909-916