Discussion

Regarding the type of collection, a higher proportion of pancreatic pseudocysts was observed, which is similar to the report by Varadarajulu et al., who found a predominance of pseudocysts (45%) [13]. This finding is expected, as pseudocysts are a frequent complication of acute pancreatitis and have also been reported in up to 25% of cases of chronic pancreatitis [14].

However, it should be noted that not all pancreatic pseudocysts require drainage. According to the guidelines of the International Association of Pancreatology/American Pancreatic Association, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, intervention is recommended only in symptomatic pseudocysts and infected collections [14-17]. Although these recommendations have evolved, early drainage is now allowed in selected cases (before four weeks), such as large symptomatic collections causing pain or obstruction, or those with an active infectious focus refractory to medical therapy.

Among the interventions performed, a necrosectomy rate of 8.6% was observed. This low prevalence can be explained by the fact that, unlike pseudocysts, necrotic collections are more viscous and contain large amounts of debris, making drainage more difficult and requiring a more complex endoscopic approach [18].

In our study, the most commonly used stent was the double pigtail plastic stent, and a LAMS was used in only 40% of cases. This distribution was mainly related to device availability at the time of the procedure rather than superiority of one device over another. However, in accordance with the literature, there is no single “best” stent; rather, each device has specific advantages depending on the type of collection, the presence of necrosis, and anatomical considerations. One advantage of LAMS is that it provides easy access for endoscopic debridement without the need for exchange [19].

Some authors have described a combined approach consisting of initial placement of a LAMS, allowing drainage of dense material, followed by removal after three to four weeks once the cavity has decreased in size, in order to reduce the risk of bleeding. This is subsequently replaced by one or two plastic pigtail stents to maintain tract patency for a longer period until complete drainage and closure of the cavity are achieved [20].

This approach was used only in selected cases of incidental LAMS removal during necrosectomy. Furthermore, rather than the type of stent used, the primary goal was to maintain a patent fistulous tract for a sufficient period to allow repeated necrosectomies when necessary and to ensure adequate resolution of the collection.

Transmural drainage was most frequently performed via the stomach (97.1%), showing no variability compared with current literature and in agreement with reports by Varadarajulu et al., where most drainages were transgastric (81.6%), followed by transduodenal (13.2%), transesophageal (4.2%), and transjejunal (1%), as well as the study by Tilara et al., in which transgastric drainage was performed in 97% of patients and transduodenal drainage in the remaining 3% [13,20]. Nevertheless, the approach may vary depending on technical feasibility, as well as the size and location of the collection.

Regarding technical success, it was achieved in 100% of cases, demonstrating the feasibility of stent placement from the initial endoscopic procedure. This finding is consistent with the clinical literature, where endoscopic intervention success rates have been reported between 85% and 93% [13-21]. This high success rate is comparable to other reports and reinforces that EUS-guided techniques are highly effective for the drainage of peripancreatic collections.

The mean post-procedural hospital stay was 3.5 days; however, this outcome was influenced by factors inherent to hospital care and not directly related to the endoscopic procedure itself.

Recurrence was observed in three cases (8.6%), which falls within the range reported in the literature (5%-32%) [13-21]. It has been described that a significant proportion of recurrences are related to unresolved underlying pancreatic duct pathology, namely ductal leakage (disconnected pancreatic duct syndrome) or pancreatic duct stenosis, making it an important indicator of procedural effectiveness.

The complication rate was 5.8%, which is lower than that reported in the literature, where complication rates associated with endoscopic procedures range from 6% to 11% [13-21]. One case of bleeding and one case of stent obstruction were reported. This finding is partially consistent with the literature, where the most common complications include hemorrhage and infectious events, as described by several authors, including Hookey et al., who reported bleeding (n = 6), pneumoperitoneum (n = 4), systemic infection, duodenal communication requiring surgical drainage, and post-ERCP pancreatitis (n = 1 each) [21].

Similarly, Arvanitakis et al. reported transient bleeding requiring transfusion and retroperitoneal leakage without clinical impact (n = 1 each) [22].

Finally, no mortality was reported in this study; however, isolated cases have been described in the literature, such as in the study by Hookey et al., where a 5% mortality rate was observed [21]. Therefore, this series demonstrated a lower mortality rate compared with some previously published reports.

Regarding the strengths of the study, the three-year study period allowed for the inclusion of a representative patient population, mainly due to the tertiary care and referral center status of the institution. This setting ensures an adequate volume of patients with more complex pathology, thereby contributing to greater experience in these types of endoscopic approaches.

Although the main limitation of this study is its retrospective design, which implies methodological constraints in the standardization of assessments, it can be concluded that there is adequate experience in the management of peripancreatic collections at this institution, with findings and outcomes comparable to those reported in the international literature.