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The following is a summary of “Predicting the need for step-up after EUS-guided drainage of peripancreatic fluid collections, including Quadrant Necrosis Infection score validation: a prospective cohort study,” published in the January 2025 issue of Gastroenterology by Vanella et al.

This study investigates the predictive factors for the necessity of step-up procedures following endoscopic ultrasound-guided drainage (EUS-FCD) of peripancreatic fluid collections (PFCs). Prior research has primarily focused on Walled-Off Necrosis (WON) and Lumen Apposing Metal Stents (LAMS), leaving a gap in understanding broader patient populations. The analysis utilized data from a prospective registry, PROTECT (NCT04813055), encompassing patients treated between 2020 and 2024. A comprehensive monthly follow-up assessed clinical success, adverse events, and recurrence rates.

The cohort consisted of 70 patients with varying PFC types: 29 post-surgical collections, 21 pseudocysts, and 20 2WONs. Treatment modalities included double-pigtail plastic stents (DPPS) in 59% of cases and LAMS in 41%. The overall clinical success rate achieved was an impressive 92.9%, although the requirement for step-up procedures, primarily endoscopic necrosectomy, was noted in 35.7% of cases.

Key findings revealed that necrosis levels exceeding 60% ([OR] = 7.7, 95% [CI] 1.4-43) and classification within the high-risk Quadrant-Necrosis-Infection (QNI) group (OR = 4.6, 95% CI 1.4-15) were significant independent predictors for the need for step-up interventions. These factors also influenced the decision-making process regarding the allocation of PFCs to either LAMS or DPPS drainage strategies. Notably, patients classified in the high-risk QNI group experienced significantly prolonged hospital stays, averaging 12 days compared to just 4 days for lower-risk patients (p = 0.004).

Furthermore, a comparison of EUS assessments with pre-procedural radiological evaluations indicated a tendency for EUS to overestimate necrotic content, as shown by a Cohen’s kappa coefficient of κ = 0.31. This discrepancy underscores the importance of EUS in accurately evaluating PFCs.

In conclusion, this study highlights the critical role of necrosis extent and QNI classification in predicting the need for step-up procedures after EUS-FCD. These findings advocate for a more personalized approach to treatment planning, enhancing patient outcomes through tailored interventions based on individual clinical profiles.

Source: sciencedirect.com/science/article/abs/pii/S0016510725000446