Introduction
Walled-off necrosis (WON) is a serious complication of severe pancreatitis, patients with necrotizing pancreatitis having an increased risk of developing diabetes mellitus (DM) (1, 2, 3). Knowledge about the effects of endoscopic treatment of pancreatic necrosis on pancreatic endocrine function is limited.
Aims & Methods
The aim of this study was to assess the frequency of new-onset diabetes (NOD) in patients with symptomatic WON after endoscopic ultrasound (EUS)-guided drainage with lumen apposing metal stents (LAMS) using a Hot AxiosTM Stent Device and to evaluate the risk factors associated with the occurrence of NOD.
Methods: We retrospectively analyzed a prospectively collected database of patients with symptomatic WON treated by EUS-guided drainage with LAMS in a tertiary referral center. The patients were followed-up for 12 months or more after stent removal. The occurrence of NOD was assessed only in patients without prior DM and it was compared to a controlled group of patients matched for age and gender. Diabetes was defined according to the American Diabetes Association (ADA) criteria.
Results
Of the 50 patients with symptomatic WON included in the study (male/female ratio, 33:17; mean age, 59.92 ±11.3), 13 patients (26%) had pre-existing DM while ten of the remaining 37 patients (27%) without prior DM developed NOD within one year after stent removal, this frequency being higher than in healthy controls (2%, p = 0.002). NOD patients were older than non-DM patients (63.5 vs. 56 years old, p=0.042) and their WON was located more frequently in the body and tail, or in the entire pancreas (p<0.001). In addition, the mean mCTSI was higher in NOD patients (p=0.019) than in non-DM patients, while direct endoscopic necrosectomy (DEN) was also performed in more patients (90% vs 59.3%), with a higher median number of DEN sessions (4 vs. 1, p<0.001). According to multivariate analysis, the number of DEN sessions was the only significant factor for NOD occurrence (OR=7.05, p=0.010). NOD patients were more likely to be non-obese (90% vs. 30%, p=0.017) compared to patients with pre-existing DM. They also had poor glycemic control (70% vs. 23.1%, p=0.040) and required more DEN sessions (4 vs. 1, p=0.017) to achieve WON resolution.
Conclusion
In patients with symptomatic WON treated by EUS-guided drainage, DM occurred in 27% of previously non-diabetic patients within one year of follow-up, which was higher than the 2% recorded in healthy controls. Patients with WON located in the body and tail or whole pancreas were more likely to develop NOD, a high number of DEN sessions being a significant risk factor for NOD occurrence.
References
1.Tu, J., Yang, Y., Zhang, J., Yang, Q., Lu, G., Li, B., et al. (2018). Effect of the disease severity on the risk of developing new-onset diabetes after acute pancreatitis. Medicine 97:e10713
2. Umapathy, C., Raina, A., Saligram, S., Tang, G., Papachristou, G. I., Rabinovitz, M., et al. (2016). Natural history after acute necrotizing pancreatitis: a large US Tertiary care experience. J. Gastrointest. Surg. 20, 1844–1853.
3. Winter Gasparoto, R. C. G., De Jorge Racy, M. C., and Campos, T. D. (2015). Long-term outcomes after acute necrotizing pancreatitis: what happens to the pancreas and to the patient? first episode. J. Pancreas 16, 159–166.
