Updated Results for Dual Modality Versus Percutaneous Drainage for the Treatment of Symptomatic Walled off Pancreatic Necrosis
Michael Gluck*, Andrew S. Ross, Shayan Irani, S. Ian Gan, Mehran Fotoohi, Robert Crane, Justin Siegal, Ellen Hauptmann, Richard a. Kozarek
Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA
Background
Treatment of symptomatic walled off pancreatic necrosis (WOPN) by dual modality-endoscopic and percutaneous-drainage (DMD) has been shown to decrease length of hospitalization (LOH), use of CT scans and drain studies by radiology in comparison to percutaneous drainage alone. Aim To demonstrate the durability of the initial conclusions as the cohort of DMD patients expanded.
Methods
A prospective database of patients undergoing DMD was analyzed and compared to patients who had standard percutaneous drainage from 2006 to the present time.
Results
41 patients had undergone DMD with 39 completing therapy, defined as removal of percutaneous drains, definitive surgery, or death. 43 patients underwent percutaneous drainage alone. Patient characteristics including age, sex, etiology of pancreatitis, and severity of pancreatitis based on computed tomography severity index were indistinguishable between the two groups. Initial endoscopic access to the necroma was obtained by endoscopic ultrasound in 30 of the 41 patients undergoing DMD. The DMD cohort had shorter mean LOH (27 vs 55 days), time until removal of percutaneous drains (78 vs 188 days), fewer CT scans (8.0 vs 14.3), drain studies (6.0 vs 13), and number of drains per patient (1.29 vs 2.0), all statistically significant. The DMD cohort also had fewer total ERCP’s (2.0 vs 2.6, p<0.026). There have been 3 total deaths in the DMD group: 1 from MRSA pneumonia during therapy for incidentally found esophageal cancer 6 months after removal of the percutaneous drain; 1 from congestive heart failure 2 weeks after discharge from hospitalization for WOPN and electing hospice; and 1 patient with multi-system organ failure during treatment for DMD who was found to have an occult pancreatic adenocarcinoma at autopsy. Three patients in the standard drainage cohort died with drains in place while in the hospital undergoing therapy. No DMD patient needed surgery or had a pancreatico-cutaneous fistula (PCF).
Conclusions
Compared to standard percutaneous drainage, DMD of WOPN reduces LOH and the use of radiological and endoscopic resources. Surgery and PCFs were avoided in patients undergoing DMD while single digit mortality was maintained.
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