Discontinuation of proton pump inhibitor use reduces the number of endoscopic procedures required for resolution of walled-off pancreatic necrosis

Patrick C Powers, Ali Siddiqui, Reem Z Sharaiha, Grace Yang, Enad Dawod, Aleksey A Novikov, Amy Javia, Cynthia Edirisuriya, Arish Noor, Tayebah Mumtaz, Usama Iqbal, David E Loren, Thomas E Kowalski, Natalie Cosgrove, Yordano Alicea, Amy Tyberg, Iman Andalib, Michel Kahaleh, Douglas G Adler, Patrick C Powers, Ali Siddiqui, Reem Z Sharaiha, Grace Yang, Enad Dawod, Aleksey A Novikov, Amy Javia, Cynthia Edirisuriya, Arish Noor, Tayebah Mumtaz, Usama Iqbal, David E Loren, Thomas E Kowalski, Natalie Cosgrove, Yordano Alicea, Amy Tyberg, Iman Andalib, Michel Kahaleh, Douglas G Adler

Abstract

Background and objectives: Endoscopic drainage/debridement of symptomatic walled off necrosis (WON) using lumen-apposing metal stents (LAMS) is both safe and effective. While endoscopic management of WON is the standard approach to treatment, the ideal concomitant medical therapy remains unclear. The purpose of this study was to further elucidate the effect of proton pump inhibitor (PPIs) therapy on the technical and clinical success of endoscopic treatment of WON.

Methods: Two hundred and seventy-two patients in 8 centers with WON managed by endoscopic drainage using LAMS were evaluated. Patients were followed for at least 6 months following treatment. The patients were divided into two groups: Those that used PPIs continuously during the therapy and those not on PPIs continuously during the interval of therapy. Outcomes included but were not limited to technical success, clinical success, number of procedures performed, and adverse events.

Results: From 2013 to 2016, 272 patients underwent WON drainage with successful transmural LAMS placement. The two groups were split evenly into PPI users and non-PPI users, and matched in regards to demographics, etiology of pancreatitis, WON size, and location. There was no difference in the technical success between the two groups (100% vs. 98.8%, P = 1), or in clinical success rates (78.7% vs. 77.9%). There was a significant difference in the required number of direct endoscopic necrosectomies to achieve clinical success in the PPI vs. non-PPI group (3.2 vs. 4.6 respectively, P < 0.01). There were significantly more cases of stent occlusion in the non-PPI group vs. PPI group (9.5% vs. 20.1% P = 0.012), but all other documented adverse events were not significantly different.

Conclusion: Discontinuing PPIs during endoscopic drainage and necrosectomy of symptomatic WON appears to reduce the number of endoscopic procedures required to achieve resolution. Continuous PPI results in higher rates of early stent occlusion.

Keywords: Direct endoscopic necrosectomy; EUS; lumen-apposing metal stent; proton pump inhibitor; walled-off necrosis.

Conflict of interest statement

None

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