S294 Endoscopic Drainage vs Surgical Necrosectomy in Walled-Off Pancreatic Necrosis: A Retrospective Cohort Analysis

Introduction: Walled-off pancreatic necrosis (WON) is a late complication of acute necrotizing pancreatitis with significant morbidity and mortality. Traditional management with surgical necrosectomy (SN) is associated with considerable complications. Minimally invasive approaches, particularly endoscopic drainage (ED), have emerged as viable alternatives. This study compares clinical outcomes between ED and SN in a large cohort. Methods: We conducted a retrospective cohort study of 250 adults with radiologically confirmed WON treated with either ED or SN between January 2020 and December 2024 at a tertiary care center. Patients undergoing hybrid or percutaneous-only approaches were excluded. Primary outcomes included in-hospital mortality and new-onset organ failure within 30 days. Secondary outcomes included clinical success, adverse events, hospital stay duration, radiologic resolution, and quality of life (SF-36 at 6 months). Multivariate regression was used to adjust for confounders. Results: Among 250 patients (125 per group), baseline demographics and disease severity were similar. ED was associated with significantly lower mortality (6.4% vs 12.0%, P = 0.04) and new-onset organ failure (9.6% vs 17.6%, P = 0.03). Clinical success was higher with ED (84% vs 76%, P = 0.02), with fewer reinterventions (16% vs 24%, P = 0.04). ED had fewer complications including bleeding (8% vs 20%, P < 0.01), infection (12% vs 24%, P = 0.01), and pancreatic fistula (2.4% vs 9.6%, P = 0.02). ED also resulted in shorter hospital stays (10.2 vs 18.6 days, P < 0.01) and faster radiologic resolution (8.5 vs 10.4 weeks, P = 0.03). At 6 months, ED patients reported significantly better SF-36 scores across all domains. Conclusion: Endoscopic drainage is associated with superior clinical outcomes compared to surgical necrosectomy in patients with WON, including lower mortality, fewer complications, shorter hospitalization, and better quality of life. These findings support ED as the preferred first-line approach in appropriately selected patients.