Effect Of Early Oral Refeeding During The Endoscopic Treatment Of Walled-Off Necrosis

Early oral refeeding is recommended in patients with severe and/or necrotizing pancreatitis. However, when walled-off necrosis (WON) is infected, patients are sometimes kept nil per os during endoscopic necrosectomy (EN) sessions in the clinical practice. In addition, the appropriate timing of oral refeeding during the endoscopic treatment of WON is not well established. The aim of this study was to explore whether the timing of oral refeeding during the endoscopic treatment of WON affects the treatment outcomes. This is a single center, retrospective analysis of consecutive patients who underwent EN for WON at The University of Tokyo hospital between May 2007 and February 2019. Patients were included only when they restarted oral refeeding during hospital stay at our hospital. Patients who restarted oral refeeding within 7 days from the initial EUS guided transmural drainage were defined as early refeeding group (E group), and restarted after 7 days were defined as late refeeding group (L group). We compared treatment outcomes of two groups. Among 48 patients who received WON treatment during study period, 30 patients underwent EUS guided transmural drainage and subsequent EN. Finally 10 patients were included in E group, and 12 in L group. Patient characteristics of 22 cases are shown in Table. The etiologies of acute pancreatitis were PEP in 7 cases (32%), gallstone in 6 (27%), alcohol in 3 (14%); and others in 6 (27%). Infectious WON was seen in 20 cases (91%). Fasting periods defined as interval between the initial drainage and oral refeeding were 2 (range 1-4) days in E group and 11.5 (8-122) days in L group respectively (P <0.01). CV catheter insertion were less in E group (30% vs. 92%, P <0.01) and CV insertion duration were 18 (range 17-24) days and 24 (range 7-190) days respectively (P = 0.53). There were no significant differences in nutritional status such as body weight loss and change in albumin between two groups. Technical success (100% vs. 100%, P = 0.99) and clinical success (100% vs. 92%, P = 0.35) were comparable between two groups. Adverse events related to endoscopic treatment were comparable between two groups (50% vs. 50%, P = 0.99), but complications unrelated to endoscopic treatment were 0% in E group and 42% (5 CV catheter infection and 1 anal fistula infection) in L group, respectively (p < 0.01). There was no recurrence pain or infection after oral refeeding regardless of its timing. Early oral refeeding during the endoscopic treatment of WON did not improve the nutritional status but decreased infectious complications, especially CV catheter infection. A large scale, prospective study is warranted to confirm our findings.