Quadrant, necrosis, and infection criteria for the risk stratification of walled-off necrosis: external validation using multi-institutional data

Hideyuki Shiomi; Tomotaka Saito; Tsuyoshi Hamada; Ryota Nakano; Shunsuke Omoto; Mamoru Takenaka; Masahiro Tsujimae; Atsuhiro Masuda; Shogo Ota; Shinya Uemura; Takuji Iwashita; Sho Takahashi; Toshio Fujisawa; Kentaro Suda; Saburo Matsubara; Kensaku Yoshida; Akinori Maruta; Yuhei Iwasa; Keisuke Iwata; Nobuhiko Hayashi; Tsuyoshi Mukai; Hiroyuki Isayama; Ichiro Yasuda; Yousuke Nakai; WONDERFUL study group in Japan

doi:10.1016/j.gie.2024.12.037

Quadrant, necrosis, and infection criteria for the risk stratification of walled-off necrosis: external validation using multi-institutional data

Gastrointest Endosc. 2025 Jan 8:S0016-5107(25)00007-0. doi: 10.1016/j.gie.2024.12.037. Online ahead of print.

Authors

Hideyuki Shiomi¹, Tomotaka Saito², Tsuyoshi Hamada³, Ryota Nakano⁴, Shunsuke Omoto⁵, Mamoru Takenaka⁵, Masahiro Tsujimae⁶, Atsuhiro Masuda⁶, Shogo Ota⁴, Shinya Uemura⁷, Takuji Iwashita⁷, Sho Takahashi⁸, Toshio Fujisawa⁸, Kentaro Suda⁹, Saburo Matsubara⁹, Kensaku Yoshida¹⁰, Akinori Maruta¹⁰, Yuhei Iwasa¹¹, Keisuke Iwata¹¹, Nobuhiko Hayashi¹², Tsuyoshi Mukai¹³, Hiroyuki Isayama⁷, Ichiro Yasuda¹², Yousuke Nakai¹⁴; WONDERFUL study group in Japan

Affiliations

¹ Division of Hepatobiliary and Pancreatic Diseases, Department of Gastroenterology, Hyogo Medical University, Hyogo, Japan. Electronic address: hideshio0403@gmail.com.
² Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
³ Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
⁴ Division of Hepatobiliary and Pancreatic Diseases, Department of Gastroenterology, Hyogo Medical University, Hyogo, Japan.
⁵ Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan.
⁶ Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan.
⁷ First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
⁸ Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.
⁹ Department of Gastroenterology and Hepatology, Saitama Medical Center, Saitama Medical University, Saitama, Japan.
¹⁰ Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan.
¹¹ Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan.
¹² Third Department of Internal Medicine, University of Toyama, Toyama, Japan.
¹³ Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan; Department of Gastroenterological Endoscopy, Kanazawa Medical University, Ishikawa, Japan.
¹⁴ Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Japan; Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan.

PMID: 39793668
DOI: 10.1016/j.gie.2024.12.037

Abstract

Background and aims: Endoscopic ultrasound-guided peripancreatic fluid drainage (EUS-PFD) with on-demand endoscopic necrosectomy, increasingly utilized to manage walled-off necrosis (WON), is associated with substantial morbidity and mortality. This multicenter study aimed to externally validate recently developed quadrant (an abdominal quadrant distribution), necrosis, and infection (QNI) criteria for risk stratification in this setting.

Methods: Of 423 patients with pancreatic fluid collections treated in a large multi-institutional cohort between 2010 and 2020, 212 with available preprocedural computed tomography images were included. Clinical outcomes between high- and low-risk groups defined according to QNI criteria were compared.

Results: The clinical success rate did not differ significantly between the QNI-high and QNI-low groups (74.4% vs. 83.5%, respectively; P = 0.12). Time to clinical success was longer in the QNI-high group compared with the QNI-low group (median, 68 vs. 46 days, respectively; P = 0.0016). Compared with the QNI-low group, the QNI-high group was associated with higher rates of percutaneous interventions, direct endoscopic necrosectomy, mortality, and adverse events. The QNI-high group was independently associated with time to clinical success (hazard ratio 0.64, 95% confidence interval 0.46-0.87; P =0.005) in multivariable Cox proportional hazards regression analysis, and with the risk of ≥grade III adverse events (odds ratio 2.93, 95% confidence interval 1.04-8.20; P = 0.04) in multivariable logistic regression analysis.

Conclusions: The QNI criteria effectively stratified time to clinical success and the risk of adverse outcomes for patients receiving EUS-PFD of WON. Further investigations could elucidate appropriate management strategies based on QNI-based risk stratification.

Keywords: QNI criteria; endoscopic ultrasound-guided peripancreatic fluid drainage; risk stratification; walled-off necrosis.