Drainage of pancreatic fluid collections in acute pancreatitis: A comprehensive overview

Abstract

Moderately severe and severe acute pancreatitis is characterized by local and systemic complications. Systemic complications predominate the early phase of acute pancreatitis while local complications are important in the late phase of the disease. Necrotic fluid collections represent the most important local complication. Drainage of these collections is indicated in the setting of infection, persistent or new onset organ failure, compressive or pressure symptoms, and intraabdominal hypertension. Percutaneous, endoscopic, and minimally invasive surgical drainage represents the various methods of drainage with each having its own advantages and disadvantages. These methods are often complementary. In this minireview, we discuss the indications, timing, and techniques of drainage of pancreatic fluid collections with focus on percutaneous catheter drainage. We also discuss the novel methods and techniques to improve the outcomes of percutaneous catheter drainage.

Keywords: Catheters; Collections; Debridement; Drainage; Pancreatitis, Acute necrotizing; Stents; Therapeutic irrigation.

Figure 1

Various types of pancreatic fluid collections according to revised Atlanta classification. A: Acute peripancreatic fluid collection (arrow); B: Acute necrotic collection; C: Pseudocyst; D: Walled off necrosis with air foci (arrow) in the collection.

Figure 2

Step-up approach to management of pancreatic fluid collections. A: Lesser sac collection with 14 F pigtail in-situ which was upgraded to 18 F; B: The patients later underwent endoscopic cystogastrostomy and necrosectomy (not shown).

Figure 3

Evolving indications of drainage. A: Large peripancreatic collection compressing the ampulla (orange arrow) causing biliary dilatation (white arrow); B: Disconnected pancreatic duct syndrome with dilated pancreatic duct communicating with the collections (arrowheads).

Figure 4

Endoscopic transmural drainage. A: Endoscopic ultrasound guided transmural puncture of the lesser sac collection with needle tip in situ (arrow); B: Guidewire (arrow) passed through the needle into the collection; C: Double pigtail cystogastrostomy catheters (arrow) in the partially drained lesser sac collection; D: Axial; E: Sagittal computed tomography images showing lumen apposing metal stents (arrows).

Figure 5

Routes of percutaneous catheter drainage. A: Retroperitoneal; B: Transperitoneal; C: Transgastric; D: Transhepatic.

Figure 6

Dual modality drainage in different patients. A: Sagittal sections showing presence of both a lumen apposing metal stent (LAMS-curved arrow) and a transperitoneal percutaneous catheter (PCD-straight arrow) in the same collection; B: Sagittal section; C: Coronal sections of a patient showing LAMS (curved arrow) in the lesser sac component and PCD (straight arrow) in the paracolic component of the same collection utilizing advantages of both types of drainages.

Figure 7

Gastrointestinal fistula formation after percutaneous catheter placement. A: Pre percutaneous catheter (PCD) computed tomography (CT) showing walled off necrosis in left paracolic gutter (PCG) and subhepatic space; B: Axial CT showing pigtail in situ in the PCG collection (arrow); C: CT-PCD gram (coronal section) showing communication of the collection with descending colon with contrast in the lumen (arrow); D: Colonoscopic image showing pigtail tip in the colon lumen.

Figure 8

Rare and overlooked complications of percutaneous catheter placement. A: Clinical photograph of a patient with percutaneous catheter drainage showing skin changes; B: Skin changes and erosions due to percutaneous catheter percutaneous catheter placement and pericatheter leak in another patient; C: Abdominal Radiograph shows broken catheter (straight arrow) in right iliac fossa. Also note the other part of the same catheter (curved arrow); D: Catheter tip fracture with shaft of catheter (curved arrow) and tip (straight arrow) seen separately on X-Ray and computed tomography.

Figure 9

Direct endoscopic necrosectomy. A: Endoscopic images showing large amount of necrotic debris within the collection; B: Snare placed into the necrotic collection using the endoscopic route; C: Partial removal of necrotic debris using snare; D: Dark necrotic residual collection seen with snare in situ.

Figure 10

Factors influencing success of percutaneous catheter. PCD: Percutaneous catheter drainage; APD: Abdominal paracentesis drainage; NS: Normal saline; STK: Streptokinase.