Predictive factors and outcomes of endoscopic necrosectomy in patients with acute pancreatitis and walled-off necrosis

Table 1 Comparison of baseline and outcome parameters of the patients in the study group, n (%)

Variable	Total (n = 104)	Necrosectomy group (n = 36)	Non-necrosectomy group (n = 68)	P value
Demographic parameters
Age (year), mean ± SD	34.93 ± 11.81	38.08 ± 10.82	33.26 ± 12.03	0.047
Gender				0.258
Male	79	25	54
Female	25	11	14
Smoking	20 (19.2)	7 (19.4)	13 (19.1)	0.968
Alcohol	37 (35.5)	12 (33.3)	25 (36.7)	0.728
Comorbidity
HTN	3 (2.8)	1 (2.7)	2 (2.9)	0.717
Diabetes mellites	6 (5.7)	3 (8.3)	3 (4.4)	1.000
Etiology
Alcohol	38 (36.5)	12 (33.3)	26 (38.2)	0.788
Biliary	41 (39.4)	16 (44.4)	25 (36.7)	0.564
Traumatic	1 (0.09)	0 (0)	1 (1.4)	0.453
Idiopathic	24 (23.0)	8 (22.2)	16 (23.5)	0.788
SIRS	66 (63.4)	31 (86.1)	35 (51.5)	0.001
Acute kidney injury	7 (6.7)	4 (11.1)	3 (4.4)	0.195
Acute lung injury	10 (9.6)	5 (13.8)	5 (7.3)	0.280
ICU admission	32 (30.7)	15 (41.6)	17 (25)	0.080
Indication of metallic stent insertion
Pain	98 (94.2)	34 (94.4)	64 (94.1)	0.946
Fever	51 (49.0)	26 (72.2)	25 (36.7)	0.001
Jaundice	8 (7.6)	4 (11.1)	4 (5.8)	0.341
Vomiting	10 (9.6)	2 (5.5)	8 (11.7)	0.307
Lump	5 (4.8)	0 (0)	5 (7.3)	0.095
Time from AP to LAMS (days)	49.04 ± 24.22	44.64 ± 23.89	51.38 ± 24.25	0.178
Hematological and Biochemical parameters, mean ± SD
Haemoglobin (gm/dL)	10.1 ± 1.86	9.23 ± 1.66	10.55 ± 1.81	0.001
Total leucocyte count/mm³	14341 ± 8054	17372 ± 7742	12908 ± 7805	0.006
Platelets (lac/mm3)	3.24 ± 1.37	3.30 ± 1.38	3.2074 ± 1.38	0.742
Urea (mg/dL)	26.4 ± 22.5	30.58 ± 32.72	24.19 ± 14.52	0.171
Creatinine (mg/dL)	0.8 ± 0.5	0.8 ± 0.6	0.7 ± 0.4	0.635
Total Bilirubin (mg/dL)	0.86 ± 1.027	1.03 ± 0.751	1.51 ± 0.631	0.186
AST (IU/L)	33.08 ± 23.8	39.17 ± 35.1	29.8 ± 14.06	0.580
ALT (IU/L)	24.5 ± 23.32	26.8 ± 31	23.3 ± 18	0.466
ALP (IU/L)	151.4 ± 94.8	186.5 ± 122	133 ± 70	0.006
Total protein (gm/dL)	6.72 ± 0.9	6.6 ± 0.8	6.7 ± 1.0	0.572
Albumin (gm/dL)	3.2 ± 0.68	2.9 ± 0.58	3.3 ± 0.6	0.001
Computed tomography imaging characteristics
Size of WON long axis	12.17 ± 3.76	13.48 ± 3.819	11.38 ± 3.37	0.005
WON location
Head	53 (50.9)	23 (63.8)	20 (29.4)	0.001
Body	99 (95.1)	35 (97.2)	64 (94.1)	0.481
Tail	76 (73.0)	30 (83.3)	46 (67.6)	0.086
Entire	26 (25)	17 (47.2)	9 (13.2)	0.001
Amount of necrosis, mean ± SD	53.98 ± 22.11	71.25 ± 12.5	48.09 ± 21.09	0.001
< 30%	21 (20.1)	1 (2.7)	20 (29.4)	0.001
> 30%	83 (79.8)	35 (97.2)	48 (70.5)
CTSI, mean ± SD	8.02 ± 1.35	8.56 ± 1.229	7.74 ± 1.334	0.003
Extension of WON	77 (74.0)	24 (66.6)	53 (77.9)	0.284
Pelvic	2 (1.9)	1 (2.7)	1 (1.4)	1.000
Paracolic	25 (24.0)	11 (30.5)	14 (20.5)	0.675
Additional drainage
PCD	13 (12.5)	6 (16.6)	7 (10.2)	0.350
DPT1	15 (14.4)	10 (27.7)	5 (7.3)	0.005
ENCD through LAMS	6 (5.7)	6 (16.6)	0 (0)	0.001
Outcome parameters
Clinical outcome: Success	85 (81.7)	25 (69.4)	60 (88.2)	0.022
Hospital stay duration	16.87 ± 9.64	21.56 ± 11.34	12.68 ± 7.95	0.001
LAMS duration	28.00 ± 10.22	31.21 ± 10.42	26.58 ± 9.80	0.033
WON recurrence in 6 months	13 (12.5)	8 (25)	5 (7.3)	0.032
Adverse events
Bleeding	6 (5.7)	2 (5.5)	4 (5.8)	0.356
Stent migration	11 (10.5)	7 (19.4)	4 (5.8)	0.136
Colonic fistula	1 (0.9)	0 (0)	1 (1.4)	0.561
6-month mortality	4 (3.8)	2 (5.5)	2 (2.9)	0.239

¹Double pig tail was placed in the lumen-apposing metal stent (LAMS) alone group while removal of LAMS, whereas in the Direct endoscopic necrosectomy group it was placed either after necrosectomy or after removal of LAMS.

HTN: Hypertension; SIRS: Systemic inflammatory response syndrome; ICU: Intensive care unit; AP: Acute pancreatitis; LAMS: Lumen-apposing metal stent; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; WON: Walled-off necrosis; CTSI: Computed tomography severity index; PCD: Percutaneous catheter drainage; DPT: Double pig tail; ENCD: Endoscopic Naso cystic drainage.

Table 2 Multivariate logistic regression analysis of predictors for necrosectomy

Variable	OR	95%CI lower	95%CI upper	P value
CTSI score	0.729	0.416	1.281	0.272
Amount of necrosis	1.085	1.026	1.148	0.004
< 30% or > 30% of necrosis	0.381	0.013	10.781	0.571
WON location - head	1.294	0.234	7.158	0.768
WON location - entire	1.125	0.168	7.512	0.903
Size of WON	1.095	0.897	1.337	0.371
SIRS	1.584	0.304	8.24	0.585
Hemoglobin	0.815	0.567	1.171	0.269
TLC	1.0	1.0	1.0	0.914
Albumin	0.438	0.142	1.348	0.15
Fever	1.937	0.526	7.127	0.32

CI: Confidence interval; OR: Odds ratio; CTSI: Computed tomography severity index;.

WON: Walled-off necrosis; LA: Largest axis; SIRS: Systemic inflammatory response syndrome; TLC: Total leukocyte count.

Table 3 Comparison of outcomes based on timing of first direct endoscopic necrosectomy, n (%)

Outcome parameter	First DEN ≤ 7 days (n = 21)	First DEN > 7 days (n = 15)	P value
Mean number of DEN sessions	1.67 ± 0.98	1.33 ± 0.49	0.244
Clinical success	16 (76.1)	12 (80)	0.806
Hospital stay duration (days), mean ± SD	22.5 ± 12.7	20.3 ± 9.3	0.288
WON recurrence within 6 months	4 (19)	4 (26.7)	1.000
6-month mortality	1 (4.8)	1 (6.7)	1.000

DEN: Direct endoscopic necrosectomy; WON: Walled-off necrosis.