Post written by Ian Holmes, MD, from Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA. 

Over the last 10 years, the management of pancreatic walled-off necrosis (WON) has evolved with the development of minimally invasive endoscopic approaches to cystgastrostomy and necrosectomy. Endoscopic necrosectomy (EN) has become a widely favored strategy because of the low rates of morbidity and mortality associated with this approach.

However, bleeding remains a heeded adverse event of EN, with reported rates of bleeding ranging up to 20% of EN procedures.

Despite the frequency of bleeding events, predictive factors for bleeding in this patient population are unknown. There is also no agreed-upon algorithm for the management of bleeding during EN.

Subsequently, we sought to clarify preprocedural risk factors for bleeding in patients undergoing endoscopic drainage or EN for WON, using a retrospective cohort of patients at our institution with pancreatitis complicated by WON.

During the study period, 536 ENs were performed in 151 patients. Intraprocedural bleeding occurred during 28 procedures (5.2%) in 18 patients (11.9%). Thrombocytopenia (P = .006), cirrhosis (P = .049), and the identification of a vessel within the cavity endoscopically (P < .001) were associated with intraprocedural bleeding. On multivariate analysis, identification of a vessel within the cavity endoscopically remained a strong predictor of bleeding (P < .001).

Endoscopic hemostasis was attempted in 8 patients (10 procedures). Eight patients (10 procedures) were managed with interventional radiology (IR)-guided embolization. Patients who required an IR intervention for hemostasis were transfused significantly more blood before the procedure than patients who did not (3.4 units vs .67 units, P = .002).

Despite the impressive safety profile of EN, bleeding remains a heeded adverse event of endoscopic therapy for WON. Thrombocytopenia and cirrhosis were found to be independent risk factors for bleeding adverse events.

In addition, identification of a vessel within the WON cavity during endoscopy was highly predictive of bleeding during EN. We suggest that these patients should be approached with caution due to the high risk of bleeding during EN.

Due to the retrospective nature of our study, there are inherent limitations, including selection bias, variable follow-up of patients, and variations in technique of the endoscopists. Further prospective studies would be useful to clarify the most critical preprocedural bleeding risk factors.

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