The role of endoscopy in the diagnosis and treatment of inflammatory pancreatic fluid collections

doi:10.1016/j.gie.2015.11.027

Gastrointestinal Endoscopy

Volume 83, Issue 3, March 2016, Pages 481-488

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Definitions

The Atlanta classification of acute pancreatitis was revised in 2012, and inflammatory PFCs are currently categorized as acute peri-PFCs, pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis (WON) (Table 2).⁶ Acute peri-PFCs occur early in pancreatitis, rarely become infected, and typically resolve spontaneously.⁷ On imaging, they appear homogenous, lack a defined wall, can be multiple, and conform to normal retroperitoneal fascial planes. Pseudocysts are fluid

Pseudocysts

Available endoscopic approaches for drainage of pseudocysts are transmural,²¹ transpapillary,21, 22, 23 or a combined transmural and transpapillary route.15, 24 Factors influencing the decision to proceed with one approach over another include the following: (1) the anatomic relationship of the collection to the stomach or to the duodenum, (2) the presence of ductal communication with the pseudocyst, (3) cyst contents, and (4) the size of the collection.

Transmural technique

Transmural drainage of pseudocysts is

WON

To drain WON endoscopically, a transmural approach similar to that described above is necessary to allow evacuation of solid material. However, the techniques used and the postprocedure management of the patient after initial drainage are more extensive than for uncomplicated pseudocysts and require highly skilled endoscopists and support staff.47, 48, 49 Traditionally, nasocystic drainage is performed in addition to the placement of 2 transmural plastic pigtail stents to facilitate the

After-procedure Care

After uncomplicated endoscopic drainage of noninfected pancreatic pseudocysts, most patients do not require hospitalization.⁵⁷ Antibiotic prophylaxis usually is prescribed after drainage.⁵⁸ A follow-up CT scan typically is obtained 4 to 6 weeks after the drainage procedure to assess for PFC resolution. The internal stents are eventually removed endoscopically after radiographic resolution is documented. In patients with chronic pancreatitis who have undergone transmural drainage, endoscopic

Adverse events of endoscopic therapy of PFCs

Serious adverse events may arise after endoscopic drainage of PFCs and include bleeding, perforation, infection, pancreatitis, aspiration, stent migration and/or occlusion, pancreatic-duct damage, adverse events related to sedation, and death. Less common events include cardiac air embolism, development of an arterial pseudoaneurysm, and inadvertent gallbladder puncture.61, 62, 63 One series of 148 patients undergoing EUS-guided transmural drainage of a mixture of pseudocysts, abscesses, and

Pseudocysts

Outcomes after attempted endoscopic therapy depend on the type of collection drained⁵⁷ and the experience of the endoscopist.⁶⁷ Pancreatic pseudocysts can be successfully drained in 82% to 100% of cases, with adverse events occurring in 5% to 16% and recurrence rates up to 18%.39, 47, 68, 69 A randomized trial comparing 20 patients undergoing open surgical cystgastrostomy to 20 patients receiving endoscopic cystgastrostomy for pancreatic pseudocyst drainage found no recurrent pseudocysts in the

Summary

1.
We recommend that endoscopic drainage of PFCs be performed only after sufficient exclusion of alternative diagnoses, such as cystic pancreatic neoplasms and pseudoaneurysms. ⊕⊕⊕⊕
2.
We recommend waiting for maturation of the cyst wall of PFCs before endoscopic intervention. ⊕⊕⊕○
3.
We recommend drainage of symptomatic pancreatic pseudocysts. ⊕⊕⊕○
4.
We suggest drainage of rapidly enlarging pancreatic pseudocysts. ⊕⊕○○
5.
We recommend drainage of all infected PFCs in patients who fail to improve with

Disclosures

V. Muthusamy is a consultant for Boston Scientific and Medtronic. K. Chathadi is a consultant for Boston Scientific. M. Khashab is a consultant for Boston Scientific and Xlumena.