Endoscopic management of walled-off necrosis (WON) has become the preferred minimally invasive approach, yet bleeding remains a significant complication. Identifying predictors of bleeding is essential to optimize patient selection, procedural planning, and postoperative monitoring. 

In this prospective cohort study, 153 patients undergoing endoscopic drainage and necrosectomy for WON were analyzed. Baseline demographics, clinical characteristics, stent type, number of necrosectomies, and nutritional status were collected. Outcomes included occurrence of bleeding and mortality. Univariate and multivariable logistic regression analyses were performed to identify predictors of bleeding. Kaplan–Meier analysis assessed bleeding risk over time.

The cohort had a mean age of 54.5 years and mean BMI of 25.3; 34.8% were female. The average WON size was 98.6 cm. Hot Axios stents were used in 68% of procedures, followed by Hanaro (18%), Spaxus (11%), and Z-EUS (1%). Coaxial pigtail stents were placed in most patients (n=137). Following LAMS placement, bleeding occurred in 15 patients (9.8%), including one death (0.65%). Univariate analysis identified increased bleeding risk with ≥4 necrosectomies (OR 4.6; 95% CI 1.0–21.4; P=0.05), parenteral nutrition use (OR 8.8; 95% CI 2.4–32.8; P=0.001), and presence of any organ failure (OR 15.4; 95% CI 4.5–52.7; P<0.001). Kaplan–Meier analysis showed no significant difference in bleeding risk over time (log-rank P=0.647). Multivariable analysis demonstrated that the presence of any organ failure was the strongest and only independent predictor of bleeding (OR 45.9; P=0.01).

Among patients undergoing endoscopic treatment of WON, organ failure was the sole independent predictor of bleeding. These findings highlight the critical role of systemic disease severity—rather than procedural factors—in anticipating bleeding complications and guiding risk stratification.