Single vs Dual Drainage of Walled Off Pancreatic Necrosis

Objectives: Walled off pancreatic necrosis (WOPN) management has shifted towards greater emphasis on endoscopic methods, though practice variation persists. Percutaneous drains are still widely utilized, with or without transmural endoscopic stents, though the clinical impact of either single or combined approach has not been clarified. We aimed to assess efficacy of first-line endoscopic drainage of WOPN, and define characteristics associated with need for step-up to additional percutaneous drain, i.e. dual modality drainage (DMD). Methods: A single-center retrospective review was performed among patients who received endoscopic ultrasound (EUS)-guided transmural drainage for WOPN as index therapy. Patient characteristics, WOPN morphology and clinical course were assessed. The primary outcome was need for step-up to DMD. Results: Fifty-six patients (32.1% women; median 54.5 years) were included, all who received initial EUS-drainage, with similar rates of LAMS usage and disconnected tail between groups. Thirty-seven patients (66.1%) were managed by endoscopic approach only (EAO). DMD patients had larger collection(s): 16.4 cm vs 11. 5 cm ( P =0.013) and more frequent pericolic extension (42.1% vs 13.5%, P =0.043). Despite additional route of drainage, DMD patients required more total endoscopy sessions (4.7 vs 3.3, P =0.010). Conclusions: In patients receiving initial EUS drainage, the rate of step-up to DMD was 33.9%, highlighting that 2/3 of those with WOPN can be successfully managed by endoscopic means alone. Large size and pericolic extension were identified as predictors for need for step-up, and such features may be useful in identifying patients who may benefit from early dual approach.