P2865 - Endoscopic vs Dual Drainage of Walled off Pancreatic Necrosis: When Is Step-up Necessary?

Jake G. Herbert, MS, DO, Patricia Carney, PhD, Gregory Cote, MD, MS, Jessica X. Yu, MD, MS, Kaveh Sharzehi, MD, MS, Gennadiy Bakis, MD, Saad Jazrawi, MD, Emily Jonica, MD
Oregon Health & Science University, Portland, OR

Introduction: Walled-off pancreatic necrosis (WOPN) interventions have shifted over recent years, now favoring non-surgical methods. While this has reduced morbidity, there remains variation in single- vs dual-approach, being endoscopist- or institution-dependent. Dual-modality drainage (DMD) consisting of percutaneous drain(s) in conjunction with endoscopically-placed transmural stent(s) has been shown to be safe and effective by providing drainage via two conduits. Endoscopic drainage has since evolved, now with wider caliber stents and earlier aggressive per-oral debridement. We aim to assess efficacy of index endoscopic drainage and define characteristics associated with need for step-up to DMD.

Methods: A retrospective single center medical record review was performed among patients who received endoscopic ultrasound (EUS)-guided transmural drainage for symptomatic WOPN between 1/2017 - 10/2022. Patients were categorized DMD if a percutaneous drain was later placed; all others were Endoscopic Approach Only (EAO). Demographics, WOPN characteristics, and details of clinical care were recorded. Outcomes were assessed over 30 days. Intergroup differences were compared using Chi square, independent t-tests and Fishers Exact test. The primary outcome was need for step-up percutaneous drainage.

Results: Fifty-six patients (32.1% women; median 54.5 years) were included, all who received initial EUS-drainage: 37 (66.1%) remained EAO. Lumen-apposing metal stents (LAMS) were utilized in similar proportions and there was equal distribution of disconnected tail in about half the patients (Table 1). The DMD patients had larger collection(s): 16.4 cm DMD vs 11. 5cm EAO (p=0.013), with more frequent pericolic extension (42.1% vs 13.5%, p=0.043). Gastric outlet obstruction (GOO) was also more common in the DMD group than EAO (84.2% vs 56.8.2%, p=0.040). DMD had longer LOS and required twice as many Cat scans. LAMS indwell time was similar between groups (24.2 days in DMV vs 28.7 days in EAO, p=0.515). Low rates of procedure-related adverse events were observed in both groups.

Discussion: In patients receiving initial EUS drainage, the rate of step-up to DMD was 33.9%, highlighting that 2/3 of those with WOPN (even ranging up to 25cm in our EAO group) can be successfully managed by endoscopic means alone, and avoid a percutaneous drain. GOO, pericolic extension, and large size were associated with need for step-up, and such features may be useful in identifying patients who may benefit from early dual approach.


Disclosures:


Jake G. Herbert, MS, DO, Patricia Carney, PhD, Gregory Cote, MD, MS, Jessica X. Yu, MD, MS, Kaveh Sharzehi, MD, MS, Gennadiy Bakis, MD, Saad Jazrawi, MD, Emily Jonica, MD. P2865 - Endoscopic vs Dual Drainage of Walled off Pancreatic Necrosis: When Is Step-up Necessary?, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.