Precision vs. cost: Endoscopic ultrasound-guided vs. conventional pancreatic cyst drainage in a resource-limited setting

Abstract Pancreatic pseudocyst is a frequent complication of pancreatitis. Endoscopic ultrasound (EUS) being the standard approach for drainage, along with conventional transgastric (CTG) remains an alternative, but comparative real-world data from resource-limited settings remain scarce. A retrospective review was conducted at a tertiary-care center in Pakistan from 2015 to 2025. Patients undergoing pseudocyst drainage via CTG or EUS were compared for demographic variables, technical success, complications, and procedure costs. Logistic regression was used to identify predictors of either modality for drainage. A total of 164 patients underwent pseudocyst drainage, including 96 (58.5%) treated with EUS-guided drainage and 68 (41.5%) with CTG. Mean age was 32.76 ± 16.65 years (range 4–77), with 42 pediatric patients. Abdominal pain was the most common presenting symptom. Pseudocysts treated with CTG were significantly larger than those treated with EUS (15.02 ± 8.20 mm vs. 8.49 ± 2.53 mm; P < 0.001). Technical success rates were comparable between groups (EUS 96.9% vs. CTG 98.5%; P = 0.499), with no significant difference in complications or 6-month clinical outcomes. EUS-guided procedures incurred higher instrument costs (PKR 330,500 vs. PKR 197,500). Larger cyst size was independently associated with CTG selection, whereas EUS was more commonly used in hospitalized patients. EUS-guided and conventional transgastric drainage demonstrate comparable safety and efficacy. In resource-limited settings, CTG remains a cost-effective option in appropriately selected patients.