Outcomes of Infected versus Symptomatic Sterile Walled-Off Pancreatic Necrosis Treated with a Minimally Invasive Therapy

BACKGROUND/AIMS: Acute pancreatitis complicated by walled-off necrosis (WON) is associated with high morbidity and mortality, and if infected, typically necessitates intervention. Clinical outcomes of infected WON have been described as poorer than those of symptomatic sterile WON. With the evolution of minimally invasive therapy, we sought to compare outcomes of infected to symptomatic sterile WON. METHODS: We performed a retrospective cohort study examining patients who were undergoing dual-modality drainage as minimally invasive therapy for WON at a high-volume tertiary pancreatic center. The main outcome measures included mortality with a drain in place, length of hospital stay, admission to intensive care unit, and development of pancreatic fistulae. RESULTS: Of the 211 patients in our analysis, 98 had infected WON. The overall mortality rate was 2.4%. Patients with infected WON trended toward higher mortality although not statistically significant (4.1% vs 0.9%, p=0.19). Patients with infected WON had longer length of hospitalization (29.8 days vs 17.3 days, p<0.01), and developed more spontaneous pancreatic fistulae (23.5% vs 7.8%, p<0.01). Multivariate analysis showed that infected WON was associated with higher odds of spontaneous pancreatic fistula formation (odds ratio, 2.65; 95% confidence interval, 1.20 to 5.85). CONCLUSIONS: This study confirms that infected WON has worse outcomes than sterile WON but also demonstrates that WON, once considered a significant cause of death, can be treated with good outcomes using minimally invasive therapy.

Double Balloon Enteroscopy in a North American Setting: A Large Single Center 5-year Experience

BACKGROUND/AIMS: Double balloon enteroscopy (DBE) allows both diagnosis and therapeutic maneuvers in the small bowel. Its use was pioneered in Europe and Asia but there remains a relative paucity of literature from North America. Our aim in this study was to determine diagnostic and therapeutic yield in a North American setting. METHODS: A five-year retrospective analysis of all patients undergoing DBE at a single tertiary care North American hospital was performed. RESULTS: Four-hundred fifty-seven procedures, 265 anterograde and 192 retrograde, were performed on 335 patients. The most common indications were obscure gastrointestinal bleeding, small bowel obstruction, and suspected masses and mucosal abnormalities. Total enteroscopy was achieved in 19 of the 89 patients who had both anterograde and retrograde procedures. Overall diagnostic yield in the determination of cause of symptoms or previous imaging was 52%. The most common causes of obscure bleeding were small bowel ulcers (10%), vascular lesions (25%) and neoplasms (10%). The most common causes of small bowel obstruction were strictures, some of which underwent dilation. Other therapeutic interventions included polypectomy, retrieval of retained capsules, stent retrievals and percutaneous enteral jejunostomy tube placement. Overall complication rates were very low (0.6%) and included medication reaction (n=1), scope dysfunction (n=1) and perforation (n=1). CONCLUSIONS: DBE can be performed safely and with good diagnostic yield in a single referral center in North America.