Endoscopic Ultrasound-Guided Management of Pancreatic Fluid Collections: Update and Review of the Literature

Abstract

Severe acute pancreatitis is often complicated by the development of pancreatic fluid collections (PFCs), which may be associated with significant morbidity and mortality. It is crucial to accurately classify these collections as a pseudocyst or walled-off necrosis (WON) given significant differences in outcomes and management. Interventions for PFCs have increasingly shifted to less invasive strategies, with endoscopic ultrasound (EUS)-guided methods being shown to be safer and equally effective as more invasive surgical techniques. In recent years, many new developments have improved the safety and efficacy of EUS-guided interventions, such as the introduction of lumen-apposing metal stents (LAMS), direct endoscopic necrosectomy (DEN) and multiple other adjunctive techniques. Despite these developments, treatment of PFCs, and infected WON in particular, continues to be associated with significant morbidity and mortality. In this article, we discuss the EUS-guided management of PFCs while reviewing the latest developments and controversies in the field. We end by summarizing our own approach to managing PFCs.

Keywords: Endosonography; Pancreatic fluid collection; Pseudocyst; Walled-off necrosis.

Fig. 1.

Computed tomography (CT) scan of a patient with a pseudocyst. The pseudocyst is surrounded by a mature wall and is free of any solid debris.

Fig. 2.

Computed tomography (CT) scan of a patient with walled-off necrosis (WON). Note the heterogeneous appearance of the collection that contains solid, necrotic debris.

Fig. 3.

Patient with symptomatic walled-off necrosis (WON) with trans-gastric lumen-apposing metal stents (LAMS) inserted under endoscopic ultrasound (EUS)-guidance.

Fig. 4.

Endoscopic view within a walled-off necrosis (WON) cavity accessed with a therapeutic gastroscope through a lumen-apposing metal stents (LAMS). Note the necrotic debris.