Introduction
Pancreatic walled-off necrosis (WON) presents a significant challenge in acute pancreatitis management, often necessitating endoscopic intervention for drainage and necrosectomy. However, the optimal selection of stent type for endoscopic drainage remains debatable. This study aimed to evaluate the utility of the QNI classification in guiding stent selection for WON drainage.
Aims & Methods
We conducted a retrospective analysis of patients who underwent endoscopic drainage and necrosectomy for symptomatic pancreatic WON at a tertiary referral center between January 2022 and September 2023. Patients were divided into two groups based on the QNI classification: Group 1 consisted of patients who had WON affecting 1 quadrant or 2 quadrants with a necrosis of less than 30%. Group 2 consisted of patients whose WON had affected 3 quadrants, 2 quadrants with 30% necrosis, or 1 quadrant with more than 60% necrosis at the time of the index procedure. A WON-based decision was made by the endoscopist regarding the use of LAMS or plastic stents. Necrosectomy was performed in cases of infection following WON drainage. Resolution was considered in clinically asymptomatic patients with WON < 30 mm at the 3-month imaging follow-up.
Results
Forty-eight patients were included in the study, with a mean age of 55.7 (±12.28) and a male-to-female ratio of 2.4:1, 20 patients in Group 1 and 28 patients in Group 2. Except for infection, which occurred more frequently in Group 2, the indications for drainage (pain, weight loss) were similar between the two groups (28% vs 5%, p=0.03). LAMS were used more frequently in group 2 than in group 1 (64% vs 40%, p=0.001). The mean number of endoscopic procedures in Group 1 was 1.7 and in Group 2 it was 3. The interval between endoscopic procedures in Group 1 and Group 2 was 20.3 days and 12.4 days, respectively (p=0.05). Clinical resolution at 3 months showed no significant difference between groups, with rates of 90% vs 85% (p=0.87), and the complication rates was 10% vs 14.2% (p=NS). Percutaneous drainage was done in 0% vs 7.14% cases, and surgery was required in 0% vs 7.1% of cases.
Conclusion
As a result of the newly proposed QNI classification system, patients can be guided in the selection of LAMS placement as well as for multidisciplinary management. Severe QNI scores may need more aggressive interventions, yet outcomes are comparable to those with milder disease.
References
Baroud, S., Chandrasekhara, V., Storm, A. C., Law, R. J., Vargas, E. J., Levy, M. J., Mahmoud, T., Bazerbachi, F., Bofill-Garcia, A., Ghazi, R., Maselli, D. B., Martin, J. A., Vege, S. S., Takahashi, N., Petersen, B. T., Topazian, M. D., & Abu Dayyeh, B. K. (2023). Novel classification system for walled-off necrosis: a step toward standardized nomenclature and risk-stratification framework. Gastrointestinal endoscopy, 97(2), 300–308.