S2275 Outcomes and Time to Resolution in Combined Endoscopic and Percutaneous Drainage of Walled-Off Necrosis in Necrotizing Pancreatitis

Introduction: In patients with complex walled-off necrosis (WON), a percutaneous drain placed by interventional radiology (IR) may be combined with cystgastrostomy for WON management. The management and outcomes of patients with both IR drain and cystgastrostomy for WON management have not been well studied. The purpose of this study is to investigate time to resolution of WON in patients with various strategies of dual therapy. Methods: A multi-centered, retrospective chart review was conducted at 6 tertiary medical centers in the US. Patients were included if they had WON managed with both cystgastrostomy and an IR drain. WON resolution was defined when all stents and drains had been removed. Data was collected on the size and location of WON, and the timing of IR drains, lumen apposing metal stents (LAMS), and double pigtail stents (DPS). The area of the WON was calculated using a formula for an oval with 2 of the largest recorded dimensions on imaging. Results: A total of 76 patients underwent both IR drainage and cystgastrostomy for WON. Thirty-nine patients were excluded because the IR drain and cystgastrostomy were not within a contiguous collection. Of the 37 remaining, the etiology of pancreatitis was most commonly gallstones (43%) and alcohol (38%). IR drain was placed first in 32.4% of patients, LAMS first in 62.2%, and both on the same day in 5.4%. The IR drain was removed first in 54% of patients, LAMS first in 46%. In patients who had IR drains placed first, the average time to WON resolution was 160 ± 93 days compared to 137 days ±131 for those who had a LAMS placed first (P = 0.598). In patients who had the IR drain removed first, the time to WON resolution was 147 ± 138 compared to 136 ± 89 for those who had LAMS removed first (P = 0.796). In this cohort, the total days from LAMS deployment to LAMS removal were over 2-thirds (77.9%) of the total WON treatment time. Conclusion: Walled-off necrosis encompasses diverse cases where various treatment algorithms are employed, tailored to specific clinical and anatomical circumstances. In the treatment of complex WON, it remains unclear whether a combined treatment strategy may hasten, or delay WON resolution. This study did not reveal treatment approaches that statistically demonstrated superior outcomes. Prospective studies are needed to determine the most effective combined strategies.