Background: Fungal infection of pancreatic fluid collections (PFCs) in severe acute pancreatitis (SAP) is under-recognized and associated with poor outcomes. Overlap with bacterial infections and the need for invasive sampling often delay diagnosis, leading to prolonged antibiotic use without the use of antifungal agents. Methods: We report three cases of SAP complicated by fungal infection of PFCs. Two patients, one with alcohol-related pancreatitis and the other with biliary pancreatitis, developed symptomatic encapsulated necrosis. Both were successfully managed with endoscopic drainage and targeted antifungal therapy against Candida albicans, achieving full resolution. The third patient, with necrotizing biliary pancreatitis, underwent multiple surgical and endoscopic interventions and developed an infection with a non-albicans Candida species. Reduced susceptibility requires individualized antifungal adjustment guided by susceptibility testing. Despite aggressive multimodal therapy, the patient progressed to multiorgan failure and died subsequently. Results: These cases emphasize the clinical impact of fungal infections in patients with SAP, particularly their association with severe disease, prolonged hospitalization, and prior antibiotic exposure. These findings highlight the prognostic value of early microbiological sampling, species-level identification, and prompt initiation of antifungal therapy. Infections caused by non-albicans species pose additional challenges due to their reduced sensitivity to standard antifungal agents. Conclusions: Fungal infection of PFCs is a clinically significant and frequently underestimated complication of SAP. Early recognition and species-directed antifungal therapy are critical for improving outcomes in high-risk patients.

ABSTRACT A 79‐year‐old man presented with fever and jaundice. Laboratory tests revealed elevated inflammatory markers and hepatobiliary enzymes. Magnetic resonance imaging revealed a 20 × 16 cm giant hepatic cyst compressing the intrahepatic bile ducts. Emergency endoscopic retrograde cholangiopancreatography revealed intrahepatic bile duct dilatation secondary to cystic compression. An endoscopic nasobiliary drainage tube was inserted. After the cholangitis improved, the tube was replaced with a plastic stent. The patient was discharged but was readmitted 11 days later with recurrent fever and loss of appetite. Computed tomography revealed thickening of the cyst wall and internal debris, consistent with an infected hepatic cyst. Given the patient's poor general condition and presence of compressed vessels and bile ducts along the percutaneous puncture route, endoscopic ultrasound‐guided cyst drainage (EUS‐CD) with nasocystic drainage was performed. After clinical improvement, surgical fenestration was attempted but aborted due to inflammation and friability with bleeding around the endosonographically/EUS‐guided created route (ESCR). On day 25 after EUS‐CD, conversion to internal trans‐ESCR drainage was performed using a 7‐Fr, 15‐cm double‐pigtail stent, and the transpapillary stent was removed because bile duct compression had resolved. The infection recurred 22 days later owing to stent occlusion, requiring stent exchange and additional drainage via ESCR. Finally, three plastic stents were placed, and the patient had no further infection recurrence. After infection control with nasocystic drainage using EUS‐CD, multiple stent placements via ESCR can provide safe, effective, and durable treatment for giant infected hepatic cysts that are unsuitable for percutaneous drainage or surgery.

The aging global population presents a growing challenge in interventional endoscopy, making the study by Sugimoto et al both timely and relevant. Their retrospective analysis provides crucial data to resolve a common clinical dilemma: Plastic stent (PS) or metal stent (MS) for endoscopic ultrasound-guided biliary drainage in patients aged 70 and older? This editorial contextualizes their key finding, that PS and MS offer comparable patency in mixed cohorts, but MS significantly prolongs time to recurrent biliary obstruction in malignant cases without antegrade stenting, into a practical decision-making framework. We argue that for benign disease, the ease of PS reintervention is paramount in a frail population. Conversely, for malignancy, the goal shifts to maximizing stent patency to minimize the physical and psychological burden of repeated procedures, firmly favoring the use of MS. This work is a significant step toward personalized, age-specific biliary drainage strategies, and we discuss the imperative for future prospective trials to solidify these recommendations.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a popular alternative for patients in whom performing endoscopic retrograde cholangiopancreatography (ERCP) is difficult; however, EUS-BD for malignant hilar biliary obstruction (MHBO) remains controversial, particularly for bilateral drainage. This study aimed to examine the efficacy of EUS-guided bilateral stent-in-stent deployment (EUS-SIS) in patients with unresectable MHBO. This retrospective study investigated consecutive patients with MHBO in whom ERCP was difficult or failed and EUS-SIS was attempted. A total of 20 patients met the inclusion criteria. Study outcomes included technical and clinical success, recurrent biliary obstruction (RBO), and other adverse events associated with EUS-SIS. The technical success rate of EUS-SIS was 75% (15/20). The main reason for the technical failure was the inability to advance the guidewire into the contralateral intrahepatic bile duct. Clinical success was achieved in all technically successful cases. The early and late adverse event rates were 5% (1/20) and 7% (1/15), respectively. The incidence rate of RBO was 33% (5/15), and reintervention for RBO via the EUS-BD route was successful in all cases. The median time to RBO was 161 days, and the median overall survival was 191 days. EUS-SIS was promising for performing bilateral drainage when ERCP failed in patients with MHBO. However, to establish this technique as a widely accepted treatment, its technical success rate needs to be improved.

Techniques of interventional endoscopy such as implantation of stents, leak closure by clips, or endoscopic suturing can help in reducing risk of an unfavorable outcome for patients with fistulas in the gastrointestinal tract. One method is endoscopic internal drainage (EID), which has been reported to have remarkable success. Because dislocation can reduce success, endoscopic suture techniques have been applied; however, devices could be cumbersome and/or expensive. The purpose of this experimental study was to evaluation the new endoscopic suturing needle-holder SutuArt for fixation of internal drains at a gastric fistula site. This suturing system is a through-the-scope needle-holder, which can be rotated within the working channel 360 degrees and maneuvered with the endoscope tip in many positions. The experiment was performed using an explanted porcine stomach with attached esophagus. Three consecutive running stitches were performed to provide sufficient fixation of the drain at an experimental “fistula” site. Afterward, the force was measured to dislocate the fixed drain. The results of 12 measurements (median duration 23 minutes; range: 19–44) at 6.7 Newton were compared with the reference value of 12 Newton (full-thickness open-stitch), thus withstanding a substantial pulling force. In conclusion, this study demonstrates the conceptual possibility of using an endoscopic needle holder for suture-fixation of a drain. Further clinical investigations are required to establish a full feasibility test of the concept.

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is effective and safe for poor surgical candidates; however, it remains technically challenging with potential serious adverse events. This study evaluated the learning curve for EUS-GBD for safe and effective procedures. From January 2016 to January 2024, 146 patients underwent EUS-GBD performed by three endosonographers. We analyzed the baseline characteristics, procedural outcomes, and learning curves using cumulative sum (CUSUM) analysis. No significant differences were found among the three operators regarding technical success (96.4% vs. 94% vs. 95.1%; p = 0.85), clinical success (96.4% vs. 92% vs. 95.1%; p = 0.61), mean procedure time (8.0 ± 5.7 vs. 9.9 ± 7.9 vs. 9.9 ± 5.1 min; p = 0.24), or procedural adverse events (12.7% vs. 20% vs. 9.8%; p = 0.35). CUSUM analysis revealed that proficiency in procedure time was achieved after performing 27 procedures. Comparing procedure time before and after achieving technical proficiency, technical success (90.6% vs. 98.8%, p = 0.04), clinical success (89.1% vs. 98.8%, p = 0.02), and procedure time (14.45 ± 6.13 min vs. 5.09 ± 2.23 min, p < 0.01) were improved. Adverse event proficiency was reached in 23 procedures, with notable improvements post-proficiency; technical success (87.5% vs. 99%, p = 0.02), clinical success (85.4% vs. 99%, p = 0.01), and procedure time were also improved (15.04 ± 6.43 min vs. 6.33 ± 3.99 min, p < 0.01). Based on CUSUM analysis, approximately 23 procedures may be required to achieve technical proficiency in EUS-GBD with regard to minimizing adverse events, while 27 procedures are necessary to reach proficiency in terms of procedure time.

Knocking stent release technique to deploy lumen-apposing metal stents during endoscopic ultrasound-guided gallbladder drainage

This study aims to evaluate the clinical outcomes of pancreaticoduodenectomy combined with longitudinal pancreatojejunostomy (PD-L) for chronic pancreatitis with a suspicious pancreatic head mass. We evaluated these derived surgical procedures with a focus on pain relief, functional preservation, and oncologic vigilance. This retrospective single-center cohort study analyzed clinical data from 20 consecutive patients diagnosed with chronic pancreatitis who underwent PD-L at the Hepatobiliary Surgery Department of the First Affiliated Hospital of Xi'an Jiaotong University between December 2021 and December 2024. We systematically analyzed perioperative parameters, morbidity profiles, and histopathological characteristics. Post-discharge monitoring focused on quantitative pain assessment, pancreatic exocrine and endocrine functional status, and surveillance. The patients' cohort comprised 20 male patients (mean age 52.3 ± 10.1years, range 32-70) who underwent PD-L procedures: open (n = 15), laparoscopic (n = 3), and robotic-assisted (n = 2) approaches. The mean operative time was (387.7 ± 75.1) minutes, with an average intraoperative blood loss of (286 ± 141.0) mL. The mean total length of hospital stay was (18.9 ± 4.6) days. Postoperative complications occurred in 2 patients: one case of abdominal hemorrhage requiring angiographic embolization and one case of delayed gastric emptying managed through endoscopic drainage. Notably, no pancreatic fistula were observed in any case. Pathology revealed chronic pancreatitis in 9 patients, PanIN in 9 (6 PanIN-1, 3 PanIN-2), and pancreatic cancer in 2. Preoperative comparisons between the CP group (n = 9) and the PanIN/malignant group (n = 11) showed no significant differences. Although considerable differences in the smoking index were observed between the two groups, they did not reach statistical significance (p = 0.081). During a median follow-up of 14.5months, 78.9% (15/19) achieved sustained pain relief without the need for analgesics. Improvements in BMI and enhancements in glycemic regulation were observed in 6 and 5 patients, respectively. PD-L is a safe and effective surgical option for selected CP patients those with a space-occupying lesion in the pancreatic head that may raise suspicion of malignancy, concurrent with calculi-associated dilatation of the main pancreatic duct in the distal pancreatic body and tail segments.

This multicenter retrospective study aimed to compare surgery-related adverse events (AEs) of percutaneous transhepatic biliary drainage (PTBD) with those of endoscopic ultrasound-guided biliary drainage (EUS-BD) for preoperative management of malignant distal bile duct obstruction (MDBO). We reviewed data from 15 centers in Japan between 2012 and 2021. Patients with MDBO who underwent PTBD or EUS-BD after failed endoscopic retrograde cholangiopancreatography (ERCP) and later underwent pancreaticoduodenectomy (PD) were included. The primary outcome was surgery-related AEs. Secondary outcomes included drainage-related outcomes, surgery-related outcomes, disease-free survival (DFS), and overall survival (OS). Risk factors associated with surgery-related AEs were also evaluated. In total, 2350 patients received biliary drainage before PD. Of the 73 patients in whom ERCP failed, 65 underwent PTBD and 11 underwent EUS-BD. EUS-BD showed a significantly higher internalization rate (100% vs. 28%, p < 0.001), fewer sessions (median 1 vs. 2, p = 0.006), and shorter hospital stay (10 vs. 22 days, p = 0.002). Surgery-related AEs were similar between groups. In the multivariate analysis, age ≥ 71 years and ASA-PS ≥ 2 were identified as significant risk factors for surgery-related AEs, whereas the drainage method was not a significant factor. No significant differences were observed in DFS or OS between the groups. Surgical-related outcomes, DFS, and OS after EUS-BD were comparable to those after PTBD; however, EUS-BD allowed a higher internalization rate, fewer sessions, and a shorter hospital stay, making it the preferred option for preoperative biliary drainage after failed ERCP.

Endoscopic biliary drainage in patients with surgically altered anatomy: the Street multicenter study.

Endoscopic ultrasound-guided biliary drainage versus percutaneous transhepatic biliary drainage: adequately designed studies are still needed.

The effectiveness of endoscopic transpapillary gallbladder drainage (ETGBD), percutaneous gallbladder drainage (PTGBD), and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) for treating acute cholecystitis in individuals with elevated surgical risk is not yet thoroughly evaluated. The clinical success, technical success, and rates of adverse events for these three therapies were assessed using a random-effects model in a network meta-analysis of 2254 patients from 17 trials. We computed risk ratios (RR), 95% confidence intervals (CI), and standard mean differences (SMD), and treatments were ranked using P-scores. PTGBD and EUS-GBD demonstrated superior technical success rates compared to ETGBD (ETGBD vs. EUS-GBD: 95% CI: 0.80-0.88, RR = 0.85; ETGBD vs. PTGBD: 95% CI: 0.79-0.86, RR = 0.83). Similarly, PTGBD and EUS-GBD achieved greater rates of clinical success than ETGBD (ETGBD vs. EUS-GBD: 95% CI: 0.75-0.86, RR = 0.81; ETGBD vs. PTGBD: 95% CI: 0.78-0.90, RR = 0.83). Procedure-related adverse effects did not differ among these three modalities. Based on ranking estimates, although EUS-GBD had the smallest likelihood of adverse events and was predicted to provide maximum clinical success, the highest technical success was probably anticipated from PTGBD. Endoscopic gallbladder drainage (EUS-GBD or ETGBD) is a preferred first-line option in centers with advanced endoscopic expertise. PTGBD remains a valuable alternative when such expertise is not available.

Abstract Introduction Acute calculous cholecystitis (AC) is a common surgical emergency with varying severity. The Tokyo Guidelines 2018 indicate that patients with grade III AC and high ASA scores are managed with a Percutaneous Cholecystostomy Drainage (PCD) to control sepsis. Currently, there are no guidelines regarding the indications, management, and follow-up of PCDs. This is a Delphi Consensus project aimed at generating guidelines for managing PCDs. Method The Irish Surgical Research Collaborative sought to generate guidelines for PCD management through a Delphi Consensus process involving a panel of experts from Ireland and the UK. The panel comprised 44 consultants specialising in general surgery and interventional radiology. Following a thorough literature review, the steering committee generated thirty-four statements shared digitally with the expert panel using Google Forms (Google LLC, Mountain View, CA, USA). Results Following three rounds, consensus was reached on nineteen statements on PCD management. PCD is an appropriate alternative strategy to cholecystectomy for surgically unfit patients with severe AC. Transhepatic drains are preferred to transperitoneal drains and should be kept for six weeks post-insertion. An outpatient cholecystogram should be performed before PCD removal. A completion cholecystectomy is feasible with low perioperative complications. Endoscopic drainage is a novel technique that should be used where available. There was no consensus on the management of AC during pregnancy, acalculous cholecystitis management, or clamping tests. Conclusions PCD is a suitable alternative to laparoscopic cholecystectomy for surgically unfit patients with severe cholecystitis. This study presents guidelines for the indications, follow-up and management of PCDs.

Abstract Aim Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is increasingly recognised internationally as a safe, minimally invasive alternative for patients unfit for emergency cholecystectomy. It also offers value as a rescue option following failed biliary drainage. Despite growing use abroad, no standardised pathway currently exists in the UK. This study evaluates the feasibility and safety of EUS-GBD in both primary and rescue settings. Method A retrospective review was conducted of 15 patients who underwent EUS-GBD at a UK tertiary centre. Nine acutely unwell patients were deemed unfit for surgery and received EUS-GBD as primary management. Six underwent the procedure as a rescue intervention after failed common bile duct stenting. All were referred after consultant-led multidisciplinary review. Demographics, indications, procedural details, outcomes, and complications were analysed. Results Technical and clinical success was achieved in all 15 cases (100%). Median age in the primary group was 80 years (44.4% female), and 77 years (33.3% female) in the rescue group. Lumen-apposing metal stents were used in all cases. No complications related to the procedure were observed (0/15), either immediately or during follow-up. These findings demonstrate consistent success across both groups, supporting the safety and feasibility of EUS-GBD in a UK setting. A draft clinical outline and supporting procedural video were included to aid future integration into routine care. Conclusions EUS-GBD is a safe and effective option for gallbladder drainage in surgically unfit and rescue cases. These findings support broader consideration and future integration into UK practice.

ABSTRACTPancreatic pseudocysts are encapsulated, enzyme‐rich peripancreatic fluid collections that typically develop following acute or chronic pancreatitis due to pancreatic ductal disruption. While commonly localized to the lesser sac, rare mediastinal extension may occur, presenting with nonspecific thoracic symptoms such as chest pain, dyspnea, or dysphagia. Cross‐sectional imaging (CT/MRI) is essential for diagnosis. Management is individualized, ranging from conservative medical therapy to endoscopic, percutaneous, or surgical drainage based on symptom severity, complications, and anatomical considerations. We report the case of a 26‐year‐old male with a history of alcohol use and smoking, presenting with cough and dyspnea. Clinical examination revealed tachypnea, hypoxia, and signs of right‐sided pleural effusion. Chest X‐ray revealed complete opacification of the right hemithorax. Diagnostic thoracentesis yielded amylase‐rich pleural fluid (11,545 IU/L). Serum amylase and lipase were also elevated. Contrast‐enhanced CT imaging demonstrated acute necrotizing pancreatitis with peripancreatic collections extending into the thoracic cavity via the esophageal hiatus, confirming a pancreatic pseudocyst with secondary massive right‐sided amylase‐rich pleural effusion. The patient was managed conservatively with antibiotics, octreotide, and ultrasound‐guided pigtail catheter drainage. The clinical course was favorable, with complete symptomatic resolution and no evidence of recurrence on follow‐up. This case underscores a rare but significant thoracic complication of acute pancreatitis manifesting as massive pleural effusion, mimicking thoracic pathology. Thus, accurate diagnosis using contrast‐enhanced CT and MRCP, along with tailored management from conservative therapy to invasive drainage, is crucial. Early recognition and multidisciplinary care ensure favorable outcomes, as highlighted in this case.

BACKGROUNDUnplanned extubation (UE) after endoscopic retrograde cholangiopancreatography plus endoscopic nasobiliary drainage (ENBD) increases patient morbidity and prolongs hospitalization duration.AIMTo construct a risk prediction model for UE in patients undergoing ENBD to provide evidence for clinical nursing.METHODSA multicenter retrospective study was conducted, collecting data from 981 patients undergoing ENBD from three hospitals in Chongqing from January 2018 to June 2024, randomly allocated to modeling and validation groups in a 7:3 ratio. Logistic regression analysis was used to screen independent risk factors, construct prediction models, and draw nomograms.RESULTSThe overall incidence of UE was 6.12% (60/981). The majority (70.00%) of extubations occurred within 24-72 h postoperatively. Multivariate logistic regression analysis identified age ≥ 61 years [odds ratio (OR) = 2.341, 95% confidence interval (CI): 1.28-4.27], smoking history (OR = 2.876, 95%CI: 1.54-5.37), prolonged fasting time (OR = 1.124, 95%CI: 1.05-1.20), prolonged catheter duration (OR = 1.286, 95%CI: 1.09-1.52), and consciousness changes (OR = 3.152, 95%CI: 1.69-5.89) were independent risk factors while serum albumin was a protective factor (OR = 0.912, 95%CI: 0.87-0.95). The model receiver operating characteristic area under curve was 0.881 with accuracy of 80.36%, sensitivity of 83.59%, and specificity of 74.88%. A nomogram total score ≥ 199 points corresponded to a high-risk threshold.CONCLUSIONThe six-factor risk prediction model had good discrimination and accuracy, which can provide clinical nursing staff with scientific evidence to identify patients at high risk and help reduce the incidence of UE.

This study aimed to evaluate adverse events (AEs) for endoscopic ultrasound-guided biliary drainage (EUS-BD) and identify risk factors for early AEs and recurrent biliary obstruction (RBO). A multicenter retrospective study was conducted using a common database of 21 Japanese referral centers. A total of 616 patients who underwent EUS-BD, including endoscopic ultrasound-guided choledochoduodenostomy (n = 107), hepaticogastrostomy (n = 487), and hepaticojejunostomy (n = 22), for malignant biliary obstruction were analyzed. Early AEs occurred in 13.6% of patients. Independent risk factors for all AEs included procedure time ≥ 32 min (odds ratio [OR] 1.82) and antiplatelet/anticoagulant use (OR 2.15). A risk factor for peritonitis included electrocautery use (OR 3.87), while bleeding risk was increased with antiplatelet/anticoagulant use (OR 7.19) and performance status > 2 (OR 5.26). The use of plastic stents was associated with a higher risk of a shorter time to RBO. AE and RBO rates did not significantly differ among the three EUS-BD approaches. Patients on antiplatelet and/or anticoagulation therapy should be aware of the increased risk of AEs of EUS-BD. In addition, it is important to minimize procedure time, avoid the use of electrocautery, and use a metal stent to prevent early AEs and RBO.

Duodenal dystrophy is a rare surgical pathology caused by presence of heterotopic pancreatic tissue in duodenal wall. The presence of heterotopic tissue may remain long-term asymptomatic. But due to provoking pancreatic tissue inflammation factors duodenal dystrophy evolves. Thereby the patients with duodenal dystrophy are mostly employable smoking and drinking alcohol men. In the literature researches are also used other names of this nosological form. The most common are paraduodenal pancreatitis and groove pancreatitis. Pathophysiology of the disease is also controversial, but two factors of development are clearly visible, such as the presence of heterotopic pancreatic tissue in duodenal wall and patient alcohol consumption. The clinical features of duodenal dystrophy are non-specific. The most common symptoms are pain in epigastrium and abdominal discomfort, postprandial nausea and vomiting, weight loss. Instrumental diagnostics reveal a thickened wall of the duodenum with the presence of cysts in it. The most sensitive and specific diagnostic methods are computed tomography, magnetic resonance imaging and endoscopic ultrasonography. Conservative treatment with synthetic somatostatin analogues is preferred as first-line therapy. The most commonly used endoscopic treatment is endoscopic drainage of the duodenal cysts, which may be associated with drug therapy. Surgical treatment methods are used primarily in cases of complicated duodenal dystrophy, the impossibility of excluding the oncological process of the affected area, and also when conservative and endoscopic methods are ineffective. Pancreaticoduodenectomy is the most preferred surgical treatment worldwide, but there has been increasing debate about its excessiveness.

Aims To investigate predictive factors in patients with non-curable malignant hilar biliary obstruction (mHBO) and identify those with a life expectancy of 30 days or less, who would not benefit from palliative biliary drainage. Materials and methods A retrospective analysis of consecutive palliative patients undergoing percutaneous or endoscopic biliary drainage for mHBO at Groote Schuur and Tygerberg Hospitals, Cape Town, between 1 January 2015 and 1 January 2023. Demographic and baseline clinical parameters, laboratory test results, tumour characteristics and intervention type were compared in patients who survived ≤ 30 days to those who survived > 30 days after index intervention. Results A total of 294 patients were included in the study, of whom 135 survived ≤ 30 days and 159 > 30 days. Regression analysis using a Cox proportional hazard model showed that Eastern Cooperative Oncology Group performance status ≥ 2, strictures secondary to hepatocellular carcinoma, serum levels of albumin < 30 g/L and serum levels of total and conjugated bilirubin > 250 μmol/L predicted survival of ≤ 30 days. Conclusions These predictive factors should be considered by the multidisciplinary team regarding the decision to perform biliary drainage during end-of-life care or rather proceed to solely medical and symptomatic relief in patients with non-curable mHBO.

Postoperative pancreatic fistula (POPF) is a serious complication that can lead to potentially fatal outcomes; therefore, early intervention with drainage is warranted whenever clinically feasible. Endoscopic ultrasound-guided transmural drainage (EUS-TD) is becoming an alternative to percutaneous drainage for managing POPF. While EUS-TD is increasingly used, there is no consensus on stent type or the need for external drainage in early postoperative EUS-TD for POPF. This study aimed to evaluate the feasibility of EUS-TD using multiple plastic stents (PSs) without external drainage for managing POPF within postoperative day 15. This retrospective case series included 11 patients who developed POPF and underwent EUS-TD within postoperative day 15 between January 2021 and June 2024. The primary outcome was clinical success of EUS-TD with multiple PSs without external drainage. Secondary outcomes included technical success, complications, length of hospital stay, and recurrence rate. Eleven POPF patients underwent EUS-TD. Two or more PSs were successfully placed in all cases, with clinical success achieved in 10 of 11 cases. One case required additional percutaneous drainage. A pseudoaneurysm rupture occurred in one case and was successfully managed with interventional radiology. The mean length of hospital stay was 19.1 days. No recurrences were observed during a median follow-up period of 26.0 months. Stents were removed after 6 months or later. EUS-TD using multiple PSs without external drainage may be a feasible approach for managing POPF within postoperative day 15. Further prospective studies are needed to validate these findings and optimize early postoperative management strategies for POPF.