The risk factors of bleeding after endoscopic ultrasonography -guided transmural drainage of peripancreatic fluid collections: A single-center experience in China

The risk factors of bleeding after endoscopic ultrasonography -guided transmural drainage of peripancreatic fluid collections: A single-center experience in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The risk factors of bleeding after endoscopic ultrasonography -guided transmural drainage of peripancreatic fluid collections: A single-center experience in China Yaoting Li, Yue Li, Tingting Yu, Senlin Hou, Wei zhang, Haiming Du, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5197445/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Endoscopic ultrasonography(EUS) guided transmural drainage has become a first-line treatment for peripancreatic fluid collections(PFCs). Postoperative bleeding may lead to severe clinical outcomes. The purpose of this study was to explore thepatient-related and surgery-related factors associtated with postoperative bleeding. Methods This is an observational cohort study. A total of 181 patients who underwent EUS drainage at our center between June 2019 and May 2023 were enrolled analyzed in the study. Postoperative bleeding complications were observed, and patient and operation-related data were collected. Univariate and multifactorial logistics regression were performed for the risk factors that may affect postoperative bleeding. Determine the risk factors affecting postoperative bleeding. Results We achieved a 100% technical success rate. A total of 14 cases(7.7%) of bleeding occurred. All bleeding patients were successfully treated by conservative, endoscopic, interventional and other treatments. Logistic regression analysis showed that cyst size was an independent risk factor for bleeding after EUS-guided transmural drainage (P = 0.006; OR,2.722; 95%CI,1.327–5.587). conclusion The cyst size was an independent risk factor for bleeding after PFC drainage. Slowing the rate of decline in intracystic pressure may reduce the risk of bleeding. EUS-guided drainage Peripancreatic fluid collections Bleeding Figures Figure 1 Figure 2 Figure 3 Introduction Peripancreatic fluid collections(PFC) is usually secondary to acute pancreatitis, chronic pancreatitis and pancreatic trauma. Treatment methods include surgery, percutaneous intervention, and endoscopic drainage. Multiple studies have demonstrated that endoscopic drainage is safe and effective( 1 , 2 ). Endoscopic drainage of PFCs was first reported in the late 1980s( 1 ). After nearly 40 years of development, this technique has become the first-line treatment for acute peripancreatic effusion( 2 – 4 ). Bleeding after EUS drainage is a rare adverse event with an incidence of about 2%-10%, and the incidence varies widely among centers due to sample size limitations( 2 , 4 ). At present, there are few studies on bleeding after EUS drainage, and only a few case reports have reported endoscopic management of bleeding. Mild bleeding can be treated conservatively, and severe bleeding requires re-interventional treatment or even surgery. This increases the length and cost of hospitalization and affects patient recovery. Therefore, it is very important to find the risk factors of bleeding after endoscopic drainage of PFCs. In this study, we aimed to determinethe related riskfactors of bleeding after EUS drainage. Methods Patients We analyzed patients who underwent EUS-guided transmural drainage in our center from June 2019 to May 2023. All patients with symptomatic PFC were collected and analyzedin the study. The inclusion criteria were: 1.symptomatic PFC; 2.PFC that was resistant to conservative treatment. The exclusion criteria were: 1. The cyst was not defined and the cyst wall was not formed; 2. Suspected hemorrhage in the cavity; 3. Suspicion of malignancy. A total of 181 patients were finally enrolled in the study. Ethics All patients were free to choose their treatment and signed a written informed consent. Patients younger than 18 years old signed an informed consent by their guardians. The study was approved by the Ethics Committee of our center. Variables Potential risk factors that may affect postoperative bleeding were collected as follows. The factors related to patients included gender,age, etiology, cyst diameter, cyst type, and cyst wall thickness. The factors associated with surgery mainly included postoperative infection and stent type, location of puncture, Number of puncture channels. Firstly, univariate regression analysis of risk factors was performed, and related factors with P < 0.05 were included in multivariate regression analysis, and independent risk factors affecting bleeding were identified. Procedure All procedures were performed by experienced endoscopists under intravenous anesthesia. Endoscopic ultrasound (ME2, OLYMPUS, JAPAN) was used to perform standard scanning of the pancreas(shown in Fig. 1 ), and bleeding and solid nodules will be excluded if detected. The cyst was then punctured with puncture needle (ECHO-19, COOK,USA) at a suitable location (stomach or duodenum) avoiding blood vessels, A 0.035-inch guidewire (Jagwire,Boston Scientific,USA) was inserted through the needle lumen into the cyst. A cystotome (10 Fr,COOK,USA) was used to dilate the puncture tract. Plastic or metal stent and nasal cyst tubes (for postoperative irrigation) were then placed depending on the size of the cyst and inside necrosis (shown in Fig. 2 and Fig. 3 ). To prevent infection, routine prophylactic treatment with antibiotics (ceftriaxone, 2g, once daily, intravenously) was given 3 days before surgery. Abdominal CT was reexamined at 7 and 30 days after surgery, and then once a month. The stent was removed when the patient's symptoms had disappeared for at least 2 weeks and CT confirmed the cyst had disappeared. Definition Postoperative fever with a temperature greater than 38.5 degrees Celsius with or without an increase in white blood cells was defined as infection. Nasal cyst tube was used for postoperative irrigation. Postoperative hemoglobin decline > 10g/L, or the occurrence of hematemesis, black stool was identified as bleeding. After the occurrence of bleeding symptoms, red blood cells were transfused in time, hemostatic drugs were applied, and endoscopic hemostasis or vascular interventional embolization was performed if necessary. If infection or bleeding is difficult to control, embolismor surgical intervention may be considered. The type of cyst was defined by the amount of solid necrotic material in the cyst. The procedure was performed by experienced endoscopists and imaging specialists. The size of the cyst and necrotic material was measured by ultrasound images and nuclear magnetic images. According to Atlanta classification, if the solid debris in the cyst was greater than 50%, it was identified as walled off necrosis(WON), and if it was less than 50%, it was identified as pancreatic pseudocyst(PPC). Statistical analysis The sample size of our study is estimated based on the number of independent variables (greater than 15 times the number of independent variables). Data were analyzed using SPSS 27.0 (SPSS Inc., Chicago, Illinois,USA). Results are expressed as medians and means and ranges. A P-value below 0.05 was considered statistically significant. Univariate analysis for screening purposes for risk factors. In addition, multivariate analysis calculating the hazard ratio using logistic binary regression was added on the factors identified by univariate analysis as independently significant for bleeding after EUS - guided transmural drainage. Results Patient and PFC Characteristics A total of 181 patients were enrolled in the study, including 111 male and 70 female with a mean age of 49 years (range 8–85 years). Their baseline characteristics were shown in Table 1. The causes of PFC were acute pancreatitis in 150 cases (82.9%), chronic pancreatitis in 17 cases (26%), surgery in 6 cases (3%) and trauma in 8 cases (4%). The median diameter of the cyst was 10.9 cm (range 4.1-25.3cm). Among these patients, 21 (11.6%) developed symptoms of infection (fever or elevated WBC count). In our process, 179 cases were punctured through the stomach and 2 cases were punctured through the duodenum. The average thickness of the cyst wall was 4.6mm (1mm-10mm). 161 patients were identified as PPC and 20 patients were identified as WON. Five patients were treated with dual-channel puncture (puncture at two locations with stent or nasal cyst tube inserted) and 176 patients were treated with single-channel puncture (puncture at only one location with stent or nasal cyst tube inserted). Technical Outcomes All patients were successfully drained by EUS and the stent (plastic or metal) was successfully removed after the cyst was identified and symptoms resolved postoperatively. The median follow-up period was 11.5 months, and 9 (4.9%) patients recurred, 7 patients were managed by re-endoscopic intervention, and 2 patient was managed by surgery. In our cohort, 22.6% of patients developed symptoms of infection. Among them, 4 patients underwent repeated endoscopic removal of necrotic tissue, The remaining 38 patients with symptoms of infection disappeared after antibiotics and nasal cyst tube irrigation. Among these patients, 14 (7.7%) had bleeding after surgery. Seven patients were treated with conservative therapy for hemostasis, two patients were treated with endoscopic self-expandable partially covered metal stent for hemostasis, three patients were treated with endoscopic hemostasis clamp, and two patients was treated with vascular embolism for hemostasis. All bleeding patients were infusedwith suspended red blood cells and rehydration to improve clinical symptoms. No serious adverse events such as piercings and death occurred. The treatment methods of endoscope hemostasis include metal stent placement, hemostatic clamp clamping, balloon packing and compression. In our patients with hemorrhage, two cases were caused by vascular variation in the cyst, and the hemostasis was successfully stopped by vascular interventional embolization. There were 5 patients with bleeding at the puncture site and through the puncture channel, and the bleeding was successfully stopped by the implantation of the self-expandable partially covered metal stent and application of the hemostatic clamp. In seven patients, the cause of bleeding was unclear, but hemostasis was eventually achieved through conservative treatment. All bleeding occurred 24 hours after the operation, the minimum time was 24 hours, and no bleeding occurred during the operation. The longest bleeding time was 7 days after surgery. Tailed characteristics of all bleeding patients are shown in Table 2. Risk factors of bleeding after EUS drainage Univariate and multivariate analyses were performed for possible factors related to bleeding after EUS-guided transmural drainage, and Univariate analysis(shown in Table 3) showed that cyst type and cyst size were risk factors for bleeding after EUS guided transmural drainage (P = 0.04 and P = 0.004). Multivariate analysis(shown in Table 4) showed that the cyst size was statistically significant (P = 0.006,OR = 2.722). Cyst size influence bleeding after EUS transmural drainage, and cyst size was an independent risk factor. The larger the cyst, the higher the risk of bleeding after endoscopic drainage. Discussion The clinical manifestations of PFC vary widely, from asymptomatic to fatal( 5 ). In general, patients with cysts smaller than 5cm in diameter or asymptomatic patients do not need intervention. Although there are many kinds of intervention methods, endoscopic EUS-guided transmural drainage has become the preferred treatment for PFC( 6 – 8 ). In a prospective study, endoscopic drainage was associated with less cost and shorter hospital stays( 8 ). Because there was no abdominal wall incision and no abdominal drainage tube, the acceptance level of patients is higher. Moreover, a number of studies have proved that EUS-guided transmural drainage was safe and effective( 9 , 10 ), which has also been confirmed in our center. Although EUS can accurately scan the blood flow of the patient's stomach wall and cysts to avoid damaging them. However, postoperative bleeding also occur after endoscopic drainage. This can lead to increased hospital costs and prolonged hospital stays, and even potentially life-threatening adverse events. Therefore, we tried to find the risk factors causing bleeding after transmural drainage of PFC in the present study. Previous studies have reported a bleeding rate of 2%-10% in EUS-guided transmural drainage( 2 , 11 ). This is biased in different centers. In our cohort, the bleeding rate after EUS-guided transmural drainage was 7.7%, which was similar to that previously reported. In univariate analysis, the etiology of cyst formation, the thickness of cyst wall and the type of scaffold had no effect on bleeding after EUS drainage. The type and size of the cyst are risk factors for bleeding after transmural drainage. The cause of bleeding after EUS-guided transmural drainage is unknown. Studies have suggested that pseudoaneurysm is an important cause of bleeding( 12 ). But it seems to be limited to intra-procedural bleeding. There are related reviews that the main causes of post-procedural bleeding are coagulation disorders and stent type( 12 , 13 ). Initially, it was thought that patients with metal stents were more likely to bleed ( 12 , 14 ). But this is controversial. Many recent studies have concluded that metal stents do not increase the risk of postoperative bleeding( 15 , 16 ). The stent type did not increase the risk of bleeding(P = 0.936)in our study. Both univariate and multivariate analysis showed that the size and type of cyst affected the bleeding after drainage. And cyst size was an independent risk factor (OR,2.722; 95%CI,1.327–5.587). For the cyst type, won increases the risk of postoperative bleeding, which may be due to chronic erosion of blood vessels due to excessive solid debris within won, leading to postoperative bleeding. In terms of cyst size, the larger the cyst, the higher the risk of bleeding after endoscopic drainage. In our study, the risk of bleeding increased significantly (24.1%) when the cyst was about 15cm in diameter. This may be due to the pressure in the sac of the larger cyst dropping too fast, causing the blood vessels in the sac to dilate rapidly, leading to bleeding. Bleeding after EUS-guided transmural drainage can be treated by conservative therapy, endoscopic therapy, vascular intervention and surgery. But so far there was no consensus or guidelines, and only a few cases have been reported( 12 ). Conservative treatment may be effective for patients with mild bleeding. For patients with severe bleeding, timely endoscopic hemostasis is necessary. In previously reported cases, endoscopic hemostasis has been remarkably effective( 17 – 19 ). The main causes of hemorrhage were hemorrhage of blood vessels in the cyst and puncture channel. For the stomach wall, the duodenal wall may be weaker and have a richer blood supply. Therefore, both puncture location and number of puncture channels may affect bleeding, but in our cohort, neither of these factors affected postoperative bleeding. This may be due to the fact that very few of our patients have undergone transduodenal and double-channel puncture. As shown, large cysts and erosion of necrotic materials may be the main causes of postoperative bleeding. Proper identification of cyst types and accelerated necrotic, solid material expulsion may reduce the risk of postoperative bleeding. At the same time, for patients with larger cysts, slowing the rate of decline in intracystic pressure may reduce the risk of bleeding. Endoscopic management of bleeding after EUS-guided transmural drainage is a very challenging procedure, therefore, identification of risk factors and preventive strategy is important.( 12 ). This study was a single-center retrospective study, and sample size limitations may have prevented us from including more risk factors in the study, which may have led us to ignore some risk factors. Overall, more research and standardized procedures for bleeding management are needed in the future. Conclusions The type size was an independent risk factor for bleeding after PFC drainage. Slowing the rate of decline in intracystic pressure may reduce the risk of bleeding. Declarations Ethics approval and consent to participate The study was a retrospective study and was approved by the Ethics Committee of the Second Hospital of Hebei Medical University Consent for publication Not Applicable Availability of data and materials The information of all patients in this retrospective study could be verified by the electronic medical record system of the Second Hospital of Hebei Medical University. The datasets generated and/or analysed during the current study are not publicly available due [REASON WHY DATA ARE NOT PUBLIC] but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding This work was supported by the Hebei Natural Science Foundation Biomedical Joint Fund Project [H2021206439]. Authors' contributions YT,L and Y,L wrote the manuscript. TT,Y; SL,H; W,Z andHM,D collected patient data and conducted follow-up. YK,H; J and T made pictures and tables and collected data. LC,Z proposed the direction as well as the final review and revision of the manuscript Acknowledgements Not applicable References Varadarajulu S, Bang JY, Phadnis MA, Christein JD, Wilcox CM. Endoscopic transmural drainage of peripancreatic fluid collections: outcomes and predictors of treatment success in 211 consecutive patients. J Gastrointest surgery: official J Soc Surg Aliment Tract. 2011;15(11):2080–8. Ng PY, Rasmussen DN, Vilmann P, Hassan H, Gheorman V, Burtea D, et al. Endoscopic Ultrasound-guided Drainage of Pancreatic Pseudocysts: Medium-Term Assessment of Outcomes and Complications. Endoscopic ultrasound. 2013;2(4):199–203. Ge PS, Weizmann M, Watson RR. Pancreatic Pseudocysts: Advances in Endoscopic Management. Gastroenterol Clin N Am. 2016;45(1):9–27. Sãftoiu A, Vilmann A, Vilmann P. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts. Endoscopic ultrasound. 2015;4(4):319. Khanna AK, Tiwary SK, Kumar P. Pancreatic pseudocyst: therapeutic dilemma. Int J Inflamm. 2012;2012:279476. AL S, RJ S. Endoscopic management of pancreatic pseudocysts. Gastroenterol Clin N Am. 2012;41(1):47–62. TL SV, CM L, ER W, ML D. EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts. Gastrointest Endosc. 2008;68(4):649–55. Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013;145(3):583–90. e1. Park DH, Lee SS, Moon SH, Choi SY, Jung SW, Seo DW, et al. Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial. Endoscopy. 2009;41(10):842–8. Guenther L, Hardt PD, Collet P. Review of current therapy of pancreatic pseudocysts. Z Gastroenterol. 2015;53(2):125–35. Shekhar C, Maher B, Forde C, Mahon BS. Endoscopic ultrasound-guided pancreatic fluid collections' transmural drainage outcomes in 100 consecutive cases of pseudocysts and walled off necrosis: a single-centre experience from the United Kingdom. Scand J Gastroenterol. 2018;53(5):611–5. TA J, LT X. Algorithm for the multidisciplinary management of hemorrhage in EUS-guided drainage for pancreatic fluid collections. World J Clin cases. 2018;6(10):308–21. JD SV. Frequency of complications during EUS-guided drainage of pancreatic fluid collections in 148 consecutive patients. J Gastroenterol Hepatol. 2011;26(10):1504–8. C GDL, KK FTB, FM D. EUS-guided drainage of peripancreatic fluid collections with lumen-apposing metal stents and plastic double-pigtail stents: comparison of efficacy and adverse event rates. Gastrointest Endosc. 2018;87(1):150–7. E V-S THB, M P-M, A S-Y JG, F, G-H, et al. Evaluation of the short- and long-term effectiveness and safety of fully covered self-expandable metal stents for drainage of pancreatic fluid collections: results of a Spanish nationwide registry. Gastrointest Endosc. 2016;84(3):450–e72. JY B. Efficacy of metal and plastic stents for transmural drainage of pancreatic fluid collections: a systematic review. Dig endoscopy: official J Japan Gastroenterological Endoscopy Soc. 2015;27(4):486–98. NA AB. Endoscopic ultrasonography-guided transmural drainage of walled-off pancreatic necrosis: Comparison between a specially designed fully covered bi-flanged metal stent and multiple plastic stents. Dig endoscopy: official J Japan Gastroenterological Endoscopy Soc. 2017;29(1):104–10. RZ S, EM D, C PKMG. Metal versus plastic for pancreatic pseudocyst drainage: clinical outcomes and success. Gastrointest Endosc. 2015;82(5):822–7. A S, L C, A S, M T. Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement of a covered self-expandable metal stent. BMC Gastroenterol. 2013;13:93. Tables Tables 1-4 are not available with this version. Additional Declarations No competing interests reported. Supplementary Files table1.docx table2.docx table3.docx table4.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5197445","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":363759959,"identity":"15adde23-81c1-47eb-a87e-0a6695de36a8","order_by":0,"name":"Yaoting Li","email":"","orcid":"","institution":"The Second Hospital of Hebei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yaoting","middleName":"","lastName":"Li","suffix":""},{"id":363759960,"identity":"3c315388-9f7d-4999-8303-17a2999b7752","order_by":1,"name":"Yue Li","email":"","orcid":"","institution":"Nanfang 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09:46:06","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":14463,"visible":true,"origin":"","legend":"","description":"","filename":"table4.docx","url":"https://assets-eu.researchsquare.com/files/rs-5197445/v1/b682a2f1b75ffe141c00632a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The risk factors of bleeding after endoscopic ultrasonography -guided transmural drainage of peripancreatic fluid collections: A single-center experience in China","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePeripancreatic fluid collections(PFC) is usually secondary to acute pancreatitis, chronic pancreatitis and pancreatic trauma. Treatment methods include surgery, percutaneous intervention, and endoscopic drainage. Multiple studies have demonstrated that endoscopic drainage is safe and effective(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEndoscopic drainage of PFCs was first reported in the late 1980s(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). After nearly 40 years of development, this technique has become the first-line treatment for acute peripancreatic effusion(\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Bleeding after EUS drainage is a rare adverse event with an incidence of about 2%-10%, and the incidence varies widely among centers due to sample size limitations(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). At present, there are few studies on bleeding after EUS drainage, and only a few case reports have reported endoscopic management of bleeding. Mild bleeding can be treated conservatively, and severe bleeding requires re-interventional treatment or even surgery. This increases the length and cost of hospitalization and affects patient recovery. Therefore, it is very important to find the risk factors of bleeding after endoscopic drainage of PFCs. In this study, we aimed to determinethe related riskfactors of bleeding after EUS drainage.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eWe analyzed patients who underwent EUS-guided transmural drainage in our center from June 2019 to May 2023. All patients with symptomatic PFC were collected and analyzedin the study. The inclusion criteria were: 1.symptomatic PFC; 2.PFC that was resistant to conservative treatment. The exclusion criteria were: 1. The cyst was not defined and the cyst wall was not formed; 2. Suspected hemorrhage in the cavity; 3. Suspicion of malignancy. A total of 181 patients were finally enrolled in the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003e All patients were free to choose their treatment and signed a written informed consent. Patients younger than 18 years old signed an informed consent by their guardians. The study was approved by the Ethics Committee of our center.\u003c/p\u003e\n\u003ch3\u003eVariables\u003c/h3\u003e\n\u003cp\u003ePotential risk factors that may affect postoperative bleeding were collected as follows. The factors related to patients included gender,age, etiology, cyst diameter, cyst type, and cyst wall thickness. The factors associated with surgery mainly included postoperative infection and stent type, location of puncture, Number of puncture channels. Firstly, univariate regression analysis of risk factors was performed, and related factors with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were included in multivariate regression analysis, and independent risk factors affecting bleeding were identified.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eAll procedures were performed by experienced endoscopists under intravenous anesthesia. Endoscopic ultrasound (ME2, OLYMPUS, JAPAN) was used to perform standard scanning of the pancreas(shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), and bleeding and solid nodules will be excluded if detected. The cyst was then punctured with puncture needle (ECHO-19, COOK,USA) at a suitable location (stomach or duodenum) avoiding blood vessels, A 0.035-inch guidewire (Jagwire,Boston Scientific,USA) was inserted through the needle lumen into the cyst. A cystotome (10 Fr,COOK,USA) was used to dilate the puncture tract. Plastic or metal stent and nasal cyst tubes (for postoperative irrigation) were then placed depending on the size of the cyst and inside necrosis (shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). To prevent infection, routine prophylactic treatment with antibiotics (ceftriaxone, 2g, once daily, intravenously) was given 3 days before surgery. Abdominal CT was reexamined at 7 and 30 days after surgery, and then once a month. The stent was removed when the patient's symptoms had disappeared for at least 2 weeks and CT confirmed the cyst had disappeared.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eDefinition\u003c/h3\u003e\n\u003cp\u003ePostoperative fever with a temperature greater than 38.5 degrees Celsius with or without an increase in white blood cells was defined as infection. Nasal cyst tube was used for postoperative irrigation. Postoperative hemoglobin decline\u0026thinsp;\u0026gt;\u0026thinsp;10g/L, or the occurrence of hematemesis, black stool was identified as bleeding. After the occurrence of bleeding symptoms, red blood cells were transfused in time, hemostatic drugs were applied, and endoscopic hemostasis or vascular interventional embolization was performed if necessary. If infection or bleeding is difficult to control, embolismor surgical intervention may be considered. The type of cyst was defined by the amount of solid necrotic material in the cyst. The procedure was performed by experienced endoscopists and imaging specialists. The size of the cyst and necrotic material was measured by ultrasound images and nuclear magnetic images. According to Atlanta classification, if the solid debris in the cyst was greater than 50%, it was identified as walled off necrosis(WON), and if it was less than 50%, it was identified as pancreatic pseudocyst(PPC).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe sample size of our study is estimated based on the number of independent variables (greater than 15 times the number of independent variables). Data were analyzed using SPSS 27.0 (SPSS Inc., Chicago, Illinois,USA). Results are expressed as medians and means and ranges. A P-value below 0.05 was considered statistically significant. Univariate analysis for screening purposes for risk factors. In addition, multivariate analysis calculating the hazard ratio using logistic binary regression was added on the factors identified by univariate analysis as independently significant for bleeding after EUS - guided transmural drainage.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cstrong\u003ePatient and PFC Characteristics\u003c/strong\u003e \u003cp\u003eA total of 181 patients were enrolled in the study, including 111 male and 70 female with a mean age of 49 years (range 8\u0026ndash;85 years). Their baseline characteristics were shown in Table\u0026nbsp;1. The causes of PFC were acute pancreatitis in 150 cases (82.9%), chronic pancreatitis in 17 cases (26%), surgery in 6 cases (3%) and trauma in 8 cases (4%). The median diameter of the cyst was 10.9 cm (range 4.1-25.3cm). Among these patients, 21 (11.6%) developed symptoms of infection (fever or elevated WBC count). In our process, 179 cases were punctured through the stomach and 2 cases were punctured through the duodenum. The average thickness of the cyst wall was 4.6mm (1mm-10mm). 161 patients were identified as PPC and 20 patients were identified as WON. Five patients were treated with dual-channel puncture (puncture at two locations with stent or nasal cyst tube inserted) and 176 patients were treated with single-channel puncture (puncture at only one location with stent or nasal cyst tube inserted).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTechnical Outcomes\u003c/strong\u003e \u003cp\u003eAll patients were successfully drained by EUS and the stent (plastic or metal) was successfully removed after the cyst was identified and symptoms resolved postoperatively. The median follow-up period was 11.5 months, and 9 (4.9%) patients recurred, 7 patients were managed by re-endoscopic intervention, and 2 patient was managed by surgery. In our cohort, 22.6% of patients developed symptoms of infection. Among them, 4 patients underwent repeated endoscopic removal of necrotic tissue, The remaining 38 patients with symptoms of infection disappeared after antibiotics and nasal cyst tube irrigation. Among these patients, 14 (7.7%) had bleeding after surgery. Seven patients were treated with conservative therapy for hemostasis, two patients were treated with endoscopic self-expandable partially covered metal stent for hemostasis, three patients were treated with endoscopic hemostasis clamp, and two patients was treated with vascular embolism for hemostasis. All bleeding patients were infusedwith suspended red blood cells and rehydration to improve clinical symptoms. No serious adverse events such as piercings and death occurred.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe treatment methods of endoscope hemostasis include metal stent placement, hemostatic clamp clamping, balloon packing and compression. In our patients with hemorrhage, two cases were caused by vascular variation in the cyst, and the hemostasis was successfully stopped by vascular interventional embolization. There were 5 patients with bleeding at the puncture site and through the puncture channel, and the bleeding was successfully stopped by the implantation of the self-expandable partially covered metal stent and application of the hemostatic clamp. In seven patients, the cause of bleeding was unclear, but hemostasis was eventually achieved through conservative treatment. All bleeding occurred 24 hours after the operation, the minimum time was 24 hours, and no bleeding occurred during the operation. The longest bleeding time was 7 days after surgery. Tailed characteristics of all bleeding patients are shown in Table\u0026nbsp;2.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRisk factors of bleeding after EUS drainage\u003c/strong\u003e \u003cp\u003eUnivariate and multivariate analyses were performed for possible factors related to bleeding after EUS-guided transmural drainage, and Univariate analysis(shown in Table\u0026nbsp;3) showed that cyst type and cyst size were risk factors for bleeding after EUS guided transmural drainage (P\u0026thinsp;=\u0026thinsp;0.04 and P\u0026thinsp;=\u0026thinsp;0.004). Multivariate analysis(shown in Table\u0026nbsp;4) showed that the cyst size was statistically significant (P\u0026thinsp;=\u0026thinsp;0.006,OR\u0026thinsp;=\u0026thinsp;2.722). Cyst size influence bleeding after EUS transmural drainage, and cyst size was an independent risk factor. The larger the cyst, the higher the risk of bleeding after endoscopic drainage.\u003c/p\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe clinical manifestations of PFC vary widely, from asymptomatic to fatal(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In general, patients with cysts smaller than 5cm in diameter or asymptomatic patients do not need intervention. Although there are many kinds of intervention methods, endoscopic EUS-guided transmural drainage has become the preferred treatment for PFC(\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In a prospective study, endoscopic drainage was associated with less cost and shorter hospital stays(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Because there was no abdominal wall incision and no abdominal drainage tube, the acceptance level of patients is higher. Moreover, a number of studies have proved that EUS-guided transmural drainage was safe and effective(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), which has also been confirmed in our center. Although EUS can accurately scan the blood flow of the patient's stomach wall and cysts to avoid damaging them. However, postoperative bleeding also occur after endoscopic drainage. This can lead to increased hospital costs and prolonged hospital stays, and even potentially life-threatening adverse events. Therefore, we tried to find the risk factors causing bleeding after transmural drainage of PFC in the present study.\u003c/p\u003e \u003cp\u003ePrevious studies have reported a bleeding rate of 2%-10% in EUS-guided transmural drainage(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This is biased in different centers. In our cohort, the bleeding rate after EUS-guided transmural drainage was 7.7%, which was similar to that previously reported. In univariate analysis, the etiology of cyst formation, the thickness of cyst wall and the type of scaffold had no effect on bleeding after EUS drainage. The type and size of the cyst are risk factors for bleeding after transmural drainage.\u003c/p\u003e \u003cp\u003eThe cause of bleeding after EUS-guided transmural drainage is unknown. Studies have suggested that pseudoaneurysm is an important cause of bleeding(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). But it seems to be limited to intra-procedural bleeding. There are related reviews that the main causes of post-procedural bleeding are coagulation disorders and stent type(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Initially, it was thought that patients with metal stents were more likely to bleed (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). But this is controversial. Many recent studies have concluded that metal stents do not increase the risk of postoperative bleeding(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The stent type did not increase the risk of bleeding(P\u0026thinsp;=\u0026thinsp;0.936)in our study. Both univariate and multivariate analysis showed that the size and type of cyst affected the bleeding after drainage. And cyst size was an independent risk factor (OR,2.722; 95%CI,1.327\u0026ndash;5.587). For the cyst type, won increases the risk of postoperative bleeding, which may be due to chronic erosion of blood vessels due to excessive solid debris within won, leading to postoperative bleeding. In terms of cyst size, the larger the cyst, the higher the risk of bleeding after endoscopic drainage. In our study, the risk of bleeding increased significantly (24.1%) when the cyst was about 15cm in diameter. This may be due to the pressure in the sac of the larger cyst dropping too fast, causing the blood vessels in the sac to dilate rapidly, leading to bleeding.\u003c/p\u003e \u003cp\u003eBleeding after EUS-guided transmural drainage can be treated by conservative therapy, endoscopic therapy, vascular intervention and surgery. But so far there was no consensus or guidelines, and only a few cases have been reported(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Conservative treatment may be effective for patients with mild bleeding. For patients with severe bleeding, timely endoscopic hemostasis is necessary. In previously reported cases, endoscopic hemostasis has been remarkably effective(\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The main causes of hemorrhage were hemorrhage of blood vessels in the cyst and puncture channel. For the stomach wall, the duodenal wall may be weaker and have a richer blood supply. Therefore, both puncture location and number of puncture channels may affect bleeding, but in our cohort, neither of these factors affected postoperative bleeding. This may be due to the fact that very few of our patients have undergone transduodenal and double-channel puncture. As shown, large cysts and erosion of necrotic materials may be the main causes of postoperative bleeding. Proper identification of cyst types and accelerated necrotic, solid material expulsion may reduce the risk of postoperative bleeding. At the same time, for patients with larger cysts, slowing the rate of decline in intracystic pressure may reduce the risk of bleeding. Endoscopic management of bleeding after EUS-guided transmural drainage is a very challenging procedure, therefore, identification of risk factors and preventive strategy is important.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This study was a single-center retrospective study, and sample size limitations may have prevented us from including more risk factors in the study, which may have led us to ignore some risk factors. Overall, more research and standardized procedures for bleeding management are needed in the future.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe type size was an independent risk factor for bleeding after PFC drainage. Slowing the rate of decline in intracystic pressure may reduce the risk of bleeding.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study was a retrospective study and was approved by the Ethics Committee of the Second Hospital of Hebei Medical University\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe information of all patients in this retrospective study could be verified by the electronic medical record system of the Second Hospital of Hebei Medical University.\u0026nbsp;The datasets generated and/or analysed during the current study are not publicly available due [REASON WHY DATA ARE NOT PUBLIC] but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Hebei Natural Science Foundation Biomedical Joint Fund Project [H2021206439].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eYT,L and Y,L wrote the manuscript. TT,Y; SL,H; W,Z andHM,D collected patient data and conducted follow-up. YK,H; J and T made pictures and tables and collected data. LC,Z proposed the direction as well as the final review and revision of the manuscript\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVaradarajulu S, Bang JY, Phadnis MA, Christein JD, Wilcox CM. Endoscopic transmural drainage of peripancreatic fluid collections: outcomes and predictors of treatment success in 211 consecutive patients. J Gastrointest surgery: official J Soc Surg Aliment Tract. 2011;15(11):2080\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg PY, Rasmussen DN, Vilmann P, Hassan H, Gheorman V, Burtea D, et al. Endoscopic Ultrasound-guided Drainage of Pancreatic Pseudocysts: Medium-Term Assessment of Outcomes and Complications. Endoscopic ultrasound. 2013;2(4):199\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGe PS, Weizmann M, Watson RR. Pancreatic Pseudocysts: Advances in Endoscopic Management. Gastroenterol Clin N Am. 2016;45(1):9\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026atilde;ftoiu A, Vilmann A, Vilmann P. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts. Endoscopic ultrasound. 2015;4(4):319.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhanna AK, Tiwary SK, Kumar P. Pancreatic pseudocyst: therapeutic dilemma. Int J Inflamm. 2012;2012:279476.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAL S, RJ S. Endoscopic management of pancreatic pseudocysts. Gastroenterol Clin N Am. 2012;41(1):47\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTL SV, CM L, ER W, ML D. EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts. Gastrointest Endosc. 2008;68(4):649\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaradarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013;145(3):583\u0026ndash;90. e1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark DH, Lee SS, Moon SH, Choi SY, Jung SW, Seo DW, et al. Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial. Endoscopy. 2009;41(10):842\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuenther L, Hardt PD, Collet P. Review of current therapy of pancreatic pseudocysts. Z Gastroenterol. 2015;53(2):125\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShekhar C, Maher B, Forde C, Mahon BS. Endoscopic ultrasound-guided pancreatic fluid collections' transmural drainage outcomes in 100 consecutive cases of pseudocysts and walled off necrosis: a single-centre experience from the United Kingdom. Scand J Gastroenterol. 2018;53(5):611\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTA J, LT X. Algorithm for the multidisciplinary management of hemorrhage in EUS-guided drainage for pancreatic fluid collections. World J Clin cases. 2018;6(10):308\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJD SV. Frequency of complications during EUS-guided drainage of pancreatic fluid collections in 148 consecutive patients. J Gastroenterol Hepatol. 2011;26(10):1504\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eC GDL, KK FTB, FM D. EUS-guided drainage of peripancreatic fluid collections with lumen-apposing metal stents and plastic double-pigtail stents: comparison of efficacy and adverse event rates. Gastrointest Endosc. 2018;87(1):150\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eE V-S THB, M P-M, A S-Y JG, F, G-H, et al. Evaluation of the short- and long-term effectiveness and safety of fully covered self-expandable metal stents for drainage of pancreatic fluid collections: results of a Spanish nationwide registry. Gastrointest Endosc. 2016;84(3):450\u0026ndash;e72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJY B. Efficacy of metal and plastic stents for transmural drainage of pancreatic fluid collections: a systematic review. Dig endoscopy: official J Japan Gastroenterological Endoscopy Soc. 2015;27(4):486\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNA AB. Endoscopic ultrasonography-guided transmural drainage of walled-off pancreatic necrosis: Comparison between a specially designed fully covered bi-flanged metal stent and multiple plastic stents. Dig endoscopy: official J Japan Gastroenterological Endoscopy Soc. 2017;29(1):104\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRZ S, EM D, C PKMG. Metal versus plastic for pancreatic pseudocyst drainage: clinical outcomes and success. Gastrointest Endosc. 2015;82(5):822\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eA S, L C, A S, M T. Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement of a covered self-expandable metal stent. BMC Gastroenterol. 2013;13:93.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1-4 are not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"EUS-guided drainage, Peripancreatic fluid collections, Bleeding","lastPublishedDoi":"10.21203/rs.3.rs-5197445/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5197445/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEndoscopic ultrasonography(EUS) guided transmural drainage has become a first-line treatment for peripancreatic fluid collections(PFCs). Postoperative bleeding may lead to severe clinical outcomes. The purpose of this study was to explore thepatient-related and surgery-related factors associtated with postoperative bleeding.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis is an observational cohort study. A total of 181 patients who underwent EUS drainage at our center between June 2019 and May 2023 were enrolled analyzed in the study. Postoperative bleeding complications were observed, and patient and operation-related data were collected. Univariate and multifactorial logistics regression were performed for the risk factors that may affect postoperative bleeding. Determine the risk factors affecting postoperative bleeding.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe achieved a 100% technical success rate. A total of 14 cases(7.7%) of bleeding occurred. All bleeding patients were successfully treated by conservative, endoscopic, interventional and other treatments. Logistic regression analysis showed that cyst size was an independent risk factor for bleeding after EUS-guided transmural drainage (P\u0026thinsp;=\u0026thinsp;0.006; OR,2.722; 95%CI,1.327\u0026ndash;5.587).\u003c/p\u003e\u003ch2\u003econclusion\u003c/h2\u003e \u003cp\u003eThe cyst size was an independent risk factor for bleeding after PFC drainage. Slowing the rate of decline in intracystic pressure may reduce the risk of bleeding.\u003c/p\u003e","manuscriptTitle":"The risk factors of bleeding after endoscopic ultrasonography -guided transmural drainage of peripancreatic fluid collections: A single-center experience in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-26 09:46:01","doi":"10.21203/rs.3.rs-5197445/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"631dd79d-04b5-4417-ba3c-0a76025996f3","owner":[],"postedDate":"November 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-26T09:53:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-26 09:46:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5197445","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5197445","identity":"rs-5197445","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}