Endoscopic Management of Peri-Pancreatic Fluid Collections

Abstract

In the past decade, there has been a progressive paradigm shift in the management of peri-pancreatic fluid collections after acute pancreatitis. Refinements in the definitions of fluid collections from the updated Atlanta classification have enabled better communication amongst physicians in an effort to formulate optimal treatments. Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocysts has emerged as the procedure of choice over surgical cystogastrostomy. The approach provides similar success rates with low complications and better quality of life compared with surgery. However, an endoscopic "step up" approach in the management of pancreatic walled-off necrosis has also been advocated. Both endoscopic and percutaneous drainage routes may be used depending on the anatomical location of the collections. New-generation large diameter EUS-specific stent systems have also recently been described. The device allows precise and effective drainage of the collections and permits endoscopic necrosectomy through the stents.

Keywords: Endoscopic necrosectomy; Endoscopic ultrasound-guided pseudocyst drainage; Endosonography; Pancreatic necrosis; Pancreatic pseudocyst.

Fig. 1

Evolution of endoscopic treatment of pancreatic fluid collections. EUS, endoscopic ultrasound; SEMS, self-expanding metallic stents; NC, nasocystic catheter.

Fig. 2

Computed tomography of (A) pancreatic pseudocyst and (B) walled-off pancreatic necrosis.

Fig. 3

Endoscopic appearance of an infected pseudocyst after two double pigtail stents were placed.

Fig. 4

(A) Transgastric and (B) percutaneous necrosectomy.

Fig. 5

Drainage with a forward viewing echoendoscope.

Fig. 6

Endoscopic ultrasound-specific stent systems: (A) NAGI stent, (B) Spaxus stent, and (C) Hot AXIOS stent.