Background and Aims
The optimal therapeutic approach for walled-off necrosis (WON) is not fully understood,
given the lack of a validated classification system. We propose a novel and robust
classification system based on radiologic and clinical factors to standardize the
nomenclature, provide a framework to guide comparative effectiveness trials, and inform
the optimal WON interventional approach.
Methods
This was a retrospective analysis of patients who underwent endoscopic management
of WON by lumen-apposing metal stent placement at a tertiary referral center. Patients
were classified according to the proposed QNI classification system: quadrant (“Q”),
represented an abdominal quadrant distribution; necrosis (“N”), denoted by the percentage
of necrosis of WON; and infection (“I”), denoted as positive blood culture and/or
systemic inflammatory response syndrome reaction with a positive WON culture. Two
blinded reviewers classified all patients according to the QNI system. Patients were
then divided into 2 groups: those with a lower QNI stratification (≤2 quadrants and ≤30%
necrosis; group 1) and those with a higher stratification (≥3 quadrants, 2 quadrants
with ≥30% necrosis, or 1 quadrant with >60% necrosis and infection; group 2). The
primary outcome was mean time to WON resolution. Secondary procedural and clinical
outcomes between the groups were compared.
Results
Seventy-one patients (75% men) were included and stratified by the QNI classification;
group 1 comprised 17 patients and group 2, 54 patients. Patients in group 2 had a
higher number of necrosectomies, longer hospital stays, and more readmissions. The
mean time to resolution was longer in group 2 than in group 1 (79.6 ± 7.76 days vs
48.4 ± 9.22 days, P = .02). The mortality rate was higher in group 2 (15% vs 0%, P = .18).
Conclusions
Despite the heterogeneous nature of WON in severe acute pancreatitis, a proposed QNI
system may provide a standardized framework for WON classification to inform clinical
trials, risk-stratify the disease course, and potentially inform an optimal management
approach.
Graphical abstract
Graphical Abstract
Abbreviations:
BISAP (Bedside Index for Severity in Acute Pancreatitis), ICU (intensive care unit), IQR (interquartile range), IR (interventional radiology), LAMS (lumen-apposing metal stent), QNI (quadrant, necrosis, infection), WON (walled-off necrosis)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: October 05, 2022
Accepted:
September 23,
2022
Received:
May 16,
2022
Footnotes
DISCLOSURE: V. Chandrasekhara: Consultant for Boston Scientific and Coviden, LP; shareholder in Nevakar Corporation. A. C. Storm: Consultant for Apollo Endosurgery, ERBE, GI Dynamics, Intuitive Surgical, and Olympus; grant support from Apollo Endosurgery, Boston Scientific, Endogenex, Endo-TAGSS, and Enterasense. R. J. Law: Consultant for ConMed, Boston Scientific, and Medtroni; royalties from UpToDate. S. S. Vege: Royalty for chapters for Uptodate. B. T. Petersen: Consultant for Pentax, Olympus, TMC-Danish Biobank, and Pfizer; investigator for AMBU and Boston Scientific. B. K. Abu Dayyeh: Consultant for Endogenex, Endo-TAGSS, Metamodix, BFKW, USGI, Boston Scientific, Medtronic, Endogastric solutions, Apollo Endosurgery, and Spatz Medical; grant support from USGI, Boston Scientific, Cairn Diagnostics, Aspire Bariatrics, Medtronic, Endosgastric solutions; research support from Apollo Endosurgery and Spatz Medical; speaker for Olympus, Johnson and Johnson, and Endogastric solutions. All other authors disclosed no financial relationships.
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