Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes

Background: Management options for symptomatic and infected walled-off pancreatic necrosis (WOPN) have evolved over the past decade from open surgical necrosectomy to more minimally invasive approaches. We reported the use of a combined percutaneous and endoscopic approach (dual modality drainage [DMD]) for the treatment of symptomatic and infected WOPN, with good short-term outcomes in a small cohort of patients. Objective: To describe the long-term outcomes of 117 patients with symptomatic and infected WOPN treated by DMD. Design: Review of a prospective, internal review board-approved database. Setting: Single, North American, tertiary-care center. Patients: All patients with symptomatic and infected WOPN treated by DMD at our institution between 2007 and 2012. Intervention: DMD of symptomatic and infected WOPN. Main Outcome Measurements: Disease-related mortality, pancreaticocutaneous fistula formation, need for early and late surgical intervention, procedure-related adverse events. Results: A total of 117 patients underwent DMD for symptomatic and infected WOPN. A total of 103 have completed treatment, with all percutaneous drains removed. Ten patients are still undergoing treatment, and 4 patients died with percutaneous drains in place (3.4% disease-related mortality). For the patients completing therapy, the median duration of follow-up was 749.5 days. No patients required surgical necrosectomy or surgical treatment of DMD-related adverse events; 3 patients required late surgery for pain (n = 2) and gastric outlet obstruction (n = 1). There were no procedure-related deaths. In patients who have completed treatment, percutaneous drains have been removed in 100%; no patients have developed pancreaticocutaneous fistulas. Limitations: Single-center design, lack of a comparison group. Conclusion: DMD for symptomatic and infected WOPN results in favorable clinical outcomes; complete avoidance of pancreaticocutaneous fistulae, surgical necrosectomy, and major procedure-related adverse events, while maintaining single-digit disease-related mortality.