Abstract
BACKGROUND: Endoscopic ultrasound-guided drainage using lumen-apposing metal stents (LAMS) has emerged as the first-line approach for managing walled-off necrosis (WON). However, certain patients require escalation to direct endoscopic necrosectomy, for which the predictive factors have not been completely defined. AIM: To determine the predictors of direct endoscopic necrosectomy following LAMS placement in patients with WON and to assess the clinical outcomes and safety. METHODS: A retrospective analysis of prospectively collected data from patients with acute pancreatitis who were admitted to the Govind Ballabh Pant Institute of Postgraduate Medical Education in Delhi, India, between January 2020 and October 2023 was conducted. Patients with acute pancreatitis and symptomatic WON who underwent LAMS placement were included in the study. Patients aged < 18 years with asymptomatic WON, pseudocysts, postsurgical collections, or a history of percutaneous drainage were excluded. Data were collected using a predesigned form. Clinical details, treatments, interventions, and outcome data were recorded. RESULTS: A total of 104 patients with symptomatic pancreatic WON who underwent LAMS placement were included in this study. Of these, 36 required endoscopic necrosectomy. Univariate analysis revealed that fever [odds ratio (OR) = 4.47, 95% confidence interval (CI): 1.85-10.79, P = 0.00], systemic inflammatory response syndrome (OR = 5.85, 95%CI: 2.03-16.83, P = 0.001), pancreatic necrosis > 30% (OR = 14.6, 95%CI: 1.87-113.86, P = 0.001), WON in the pancreatic head (OR = 4.246, 95%CI: 1.80-10.0, P = 0.001), and collection size (OR = 1.18, 95%CI: 1.04-1.34, P = 0.009) were the predictors of endoscopic necrosectomy. Subsequently, multivariate analysis indicated that the extent of necrosis was an independent predictor of the requirement for necrosectomy (OR = 1.085, 95%CI: 1.026-1.148, P < 0.004). Clinical success was higher in the non-necrosectomy group than in the necrosectomy group (88.2% vs 69.4%). CONCLUSION: Early identification of these predictive variables can guide treatment planning for WON and facilitate early necrosectomy, thereby improving the clinical outcomes.