Prognostic factors analysis of ultrasound-guided percutaneous puncture drainage in severe acute pancreatitis with peripancreatic fluid collection

Abstract

BACKGROUND

Severe acute pancreatitis (SAP) is a critical illness associate with mortality between 15%-30%, and very frequently complicated by peripancreatic fluid collections (PFC) in more than 80% of necrotizing pancreatitis. Ultrasound-guided percutaneous puncture drainage (PPD) has become the mainstay of minimal invasive treatment for PFC, but clinical outcomes after the therapeutic procedure differ significantly from patient to patient. Drainage success independent predictors are not well defined, indicating a need for systematic identification of prognostic factors affecting drainage to optimize patient selection and individualized treatment strategies.

AIM

To identify potential independent predictors for drainage success and failure, evaluate the influence of the timing and characteristics of the collection on clinical outcomes, and generate evidence-based criteria to optimize digestive tract drainage in this high-risk cohort.

METHODS

A retrospective study was performed for 134 SAP patients who underwent PPD under ultrasound guidance to treat PFC at the Department of Emergency of Hangzhou First People’s Hospital from January 2019 to December 2024. All patients fulfilled the revised Atlanta Classification criteria for SAP, and symptomatic PFC was diagnosed by computed tomography (CT). The Hangzhou First People’s Hospital Ethics Committee approved the study protocol. Patients were categorized into good-prognosis and poor-prognosis groups by a composite endpoint of in-hospital mortality, need for emergent surgical intervention, or organ failure greater than 14 days. Univariate and multivariate time logistic regression analyses were performed to determine independent prognostic factors. Subgroup analyses assessed clinical outcomes based on timing of drainage (early: ≤ 72 hours or late: > 72 hours from diagnosis) and collection type [acute PFC/pseudocyst vs walled-off necrosis (WON)].

RESULTS

Of the 134 SAP patients treated by ultrasound-guided PPD for PFC, good prognosis and poor prognosis were observed in 82 (61.2%) and 52 (38.8%) cases, respectively. The clinical success rate of PPD was 71.6% (96/134) in total. Univariate analysis indicated that Acute Physiology and Chronic Health Evaluation (APACHE) II score ≥ 17, infected necrosis confirmed, treatment at > 72 hours from diagnosis, CT severity index ≥ 8, organ failure of ≥ 2 systems, C-reactive protein ≥ 300 mg/L when performing drainage, collection volume ≥ 400 mL and WON type and serum albumin < 30 g/L were significant prognostic factors (all P < 0.05). APACHE II score ≥ 17 [odds ratio (OR) = 5.82, 95% confidence interval (CI): 2.38-14.22], confirmed infected necrosis (OR = 4.16, 95%CI: 1.76-9.84), drainage timing > 72 hours (OR = 3.74, 95%CI: 1.58-8.86), CT severity index ≥ 8 (OR = 3.28, 95%CI: 1.38-7.80) and multisystem organ failure (OR = 3.06, 95%CI: 1.23-7.62) were identified as independent predictors of poor prognosis based on multivariate logistic regression (all P < 0.05). Early drainage (≤ 72 hours) showed significantly higher clinical success rate (82.9% vs 59.4%, P = 0.004), shorter in intensive care units stay (8.4 days vs 14.8 days, P < 0.001), and lower in-hospital mortality rate (5.7% vs 21.9%, P = 0.011). Compared to patients with acute PFC/pseudocyst, those with WON type had significantly worse outcomes as shown by lower clinical success rates (57.9% vs 89.7%, P < 0.001) and higher mortality (21.1% vs 3.4%, P = 0.003).

CONCLUSION

Ultrasound-guided PPD is an effective minimally invasive approach for the management of PFC associated with SAP, with a clinical success rate of 71.6%. Independent prognostic factors include APACHE II score, confirmed infected necrosis, drain timing, CT severity and multisystem organ failure. Early draining by 72 hours and correct pre-procedural risk stratification are all important to improve clinical outcomes. WON type collections may be where more aggressive drainage strategies and monitoring is needed. These results support evidence-based, individualized decision making for drainage in SAP patients with PFC.

Keywords: Severe acute pancreatitis; Peripancreatic fluid collection; Ultrasound-guided drainage; Percutaneous catheter drainage; Prognostic factors

Core Tip: This study identifies key prognostic factors influencing outcomes of ultrasound-guided percutaneous puncture drainage in severe acute pancreatitis with peripancreatic fluid collections. Independent predictors of poor prognosis include high Acute Physiology and Chronic Health Evaluation II score, infected necrosis, delayed drainage (> 72 hours), elevated computed tomography severity index, multisystem organ failure, high C-reactive protein levels, large collection volume, and hypoalbuminemia. Early drainage (≤ 72 hours) was associated with higher clinical success, reduced intensive care units and hospital stay, and lower mortality. Walled-off necrosis showed significantly worse outcomes compared to fluid collections without necrosis. These findings support early intervention and comprehensive pre-procedural risk stratification to guide individualized drainage strategies and improve clinical outcomes.