金属ステントによる内視鏡超音波ガイド下壊死性集合体ドレナージ再介入：高リスク形態の特定

Endoscopic ultrasound (EUS)-guided drainage with metal stents is a standard therapy for walled-off necrosis (WON). However, some patients require re-interventions such as stent unclogging, necrosectomy or percutaneous drainage. This study aimed at identifying predictors of re-intervention to facilitate risk stratification and optimize management.

This study included consecutive patients who underwent EUS-guided WON drainage with metal stents between January 2023 and December 2024 at a tertiary referral center. Demographic, clinical and radiological data was collected prospectively. Multi-variate logistic regression identified independent predictors of re-intervention. Model performance was evaluated using receiver operating characteristic (ROC) curve, calibration plot and decision curve analysis. Model's diagnostic performance was evaluated in the validation cohort.

Of 500 patients (83.2% male), 28.6% had alcohol-related and 10% had biliary pancreatitis. Re-intervention was required in 24% (n = 120), primarily for stent unclogging (85.8%), nasocystic tube placement (70%) and necrosectomy (50%). Independent predictors of re-intervention included WON size (odds ratio [OR] 1.38; 95% confidence interval [CI], 1.25-1.52), paracolic extension (OR 9.96; 95% CI, 1.77-55.98) and solid debris content (OR 1.10; 95% CI, 1.08-1.13). The model demonstrated good discrimination (area under the curve [AUC] = 0.85) and calibration (Hosmer-Lemeshow p = 0.19). The overall accuracy of the model in the validation cohort was 86.67% (95% CI, 73.21-94.95%). Adverse events occurred in 6% of patients, including bleeding (n = 11), stent migration (n = 13) and sepsis-related death (n = 6).

Larger WON size, paracolic extension and higher solid debris content are independent predictors of re-intervention after EUS-guided drainage. Early identification of these factors may allow for individualized step-up therapy and improved clinical outcomes.