Choosing Wisely: Tailored Drainage Strategies for Peripancreatic Fluid Collections—A Tertiary Center’s Experience

<b>Introduction</b>: The management of symptomatic peripancreatic fluid collections (PFCs), including pancreatic pseudocysts (PPs) and walled-off necrosis (WON), remains a clinical challenge. <b>Methods</b>: We conducted a single-center retrospective cohort study to compare the efficacy, safety, and cost of endoscopic drainage (lumen-apposing metal stent vs. double pigtail stent) and percutaneous drainage for PFCs. From an initial cohort of 75 patients with symptomatic PFCs between 2020 and 2025, 63 underwent drainage procedures. Primary endpoints were the clinical success, defined as >50% collection size reduction, and the need for direct endoscopic necrosectomy (DEN). Secondary endpoints included adverse events, recurrence rates, length of hospital stay (LOS), and procedural costs. <b>Results</b>: In our study, endoscopic drainage proved high clinical efficacy for PFCs, especially PPs. Once a technique was chosen, complication rates were comparable, indicating no clear safety advantage for either approach. While percutaneous drainage relieved symptoms and reduced collection size in half of the cases, the other half had only transient or partial improvement. When comparing endoscopic drainage techniques, median costs and length of hospital stay trended higher for lumen-apposing metal stent (LAMS) than double pigtail stent (DPS), but the differences were not statistically significant. However, the "other" group proved markedly higher costs and the longest mean hospital stay. <b>Conclusions</b>: The choice of drainage technique impacts short-term outcomes and safety profile in managing PFCs. Our findings support a tailored, step-up approach, prioritizing endoscopic ultrasound-guided drainage based on PFC characteristics to optimize clinical outcomes.