Endoscopic management of walled-off pancreatic fluid collections: Efficacy and complications
- Douglas A Howell, MD, FASGE, FACG
Douglas A Howell, MD, FASGE, FACG
- Section Editor — EUS/ERCP
- Assistant Clinical Professor of Medicine, Tufts Medical School Director,
- Pancreaticobiliary Center Director, Advanced Interventional Endoscopy Fellowship, Maine Medical Center
- Raj J Shah, MD, FASGE, AGAF
Raj J Shah, MD, FASGE, AGAF
- Professor of Medicine, University of Colorado School of Medicine
- Director, Pancreaticobiliary Endoscopy
- Digestive Health Center, University of Colorado Hospital, Anschutz Medical Campus
Walled-off pancreatic fluid collections are often the result of acute pancreatitis. They may also be seen in patients with chronic pancreatitis and in patients who have suffered blunt or penetrating pancreatic trauma. Endoscopic drainage of walled-off pancreatic fluid collections by expert endoscopists is an accepted alternative to surgery when intervention is indicated. Its advantages over percutaneous drainage are the ability to place multiple internal drains through one puncture site and the avoidance of the development of a pancreaticocutaneous fistula for walled-off pancreatic fluid collections that communicate with the pancreatic duct. (See "Walled-off pancreatic fluid collections (including pseudocysts)".)
In the past, many of these lesions were referred to as pseudocysts. However, in 2013, the terminology used to describe pancreatic fluid collections that develop following acute pancreatitis was updated, and the majority of walled-off pancreatic fluid collections now fall into the category of walled-off pancreatic necrosis. (See "Endoscopic management of walled-off pancreatic fluid collections: Techniques", section on 'Definitions'.)
This topic will review the efficacy and complications of endoscopic management of walled-off pancreatic fluid collections. The classification of pancreatic cysts, the diagnosis of walled-off pancreatic fluid collections, and the techniques used in the endoscopic management of walled-off pancreatic fluid collections are discussed separately. (See "Classification of pancreatic cysts" and "Walled-off pancreatic fluid collections (including pseudocysts)" and "Endoscopic management of walled-off pancreatic fluid collections: Techniques".)
In 2013, a revision of the Atlanta classification of acute pancreatitis was published that updated the terminology used to describe inflammatory pancreatic fluid collections to better reflect the underlying pathophysiology . According to the revised Atlanta classification, inflammatory pancreatic fluid collections include acute peripancreatic fluid collections, pseudocysts, acute necrotic collections, and walled-off pancreatic necrosis  (see "Clinical manifestations and diagnosis of acute pancreatitis", section on 'Local complications' and "Classification of pancreatic cysts"):
●Acute peripancreatic fluid collections occur in the setting of acute interstitial pancreatitis within four weeks of the onset of pancreatitis. They are typically extra-pancreatic and do not have a definable wall. The fluid contains no solid material, and there is no pancreatic necrosis present.
- Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102.
- Acevedo-Piedra NG, Moya-Hoyo N, Rey-Riveiro M, et al. Validation of the determinant-based classification and revision of the Atlanta classification systems for acute pancreatitis. Clin Gastroenterol Hepatol 2014; 12:311.
- Jacobson BC, Baron TH, Adler DG, et al. ASGE guideline: The role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory fluid collections of the pancreas. Gastrointest Endosc 2005; 61:363.
- Kozarek RA, Ball TJ, Patterson DJ, et al. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections. Gastroenterology 1991; 100:1362.
- Antillon MR, Shah RJ, Stiegmann G, Chen YK. Single-step EUS-guided transmural drainage of simple and complicated pancreatic pseudocysts. Gastrointest Endosc 2006; 63:797.
- Seewald S, Groth S, Omar S, et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos). Gastrointest Endosc 2005; 62:92.
- Kahaleh M, Shami VM, Conaway MR, et al. Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective comparison with conventional endoscopic drainage. Endoscopy 2006; 38:355.
- Hookey LC, Debroux S, Delhaye M, et al. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc 2006; 63:635.
- Krüger M, Schneider AS, Manns MP, Meier PN. Endoscopic management of pancreatic pseudocysts or abscesses after an EUS-guided 1-step procedure for initial access. Gastrointest Endosc 2006; 63:409.
- Baron TH, Harewood GC, Morgan DE, Yates MR. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc 2002; 56:7.
- Cahen D, Rauws E, Fockens P, et al. Endoscopic drainage of pancreatic pseudocysts: long-term outcome and procedural factors associated with safe and successful treatment. Endoscopy 2005; 37:977.
- Barthet M, Sahel J, Bodiou-Bertei C, Bernard JP. Endoscopic transpapillary drainage of pancreatic pseudocysts. Gastrointest Endosc 1995; 42:208.
- Binmoeller KF, Seifert H, Walter A, Soehendra N. Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 1995; 42:219.
- Catalano MF, Geenen JE, Schmalz MJ, et al. Treatment of pancreatic pseudocysts with ductal communication by transpapillary pancreatic duct endoprosthesis. Gastrointest Endosc 1995; 42:214.
- Smits ME, Rauws EA, Tytgat GN, Huibregtse K. The efficacy of endoscopic treatment of pancreatic pseudocysts. Gastrointest Endosc 1995; 42:202.
- Beckingham IJ, Krige JE, Bornman PC, Terblanche J. Long term outcome of endoscopic drainage of pancreatic pseudocysts. Am J Gastroenterol 1999; 94:71.
- Trevino JM, Tamhane A, Varadarajulu S. Successful stenting in ductal disruption favorably impacts treatment outcomes in patients undergoing transmural drainage of peripancreatic fluid collections. J Gastroenterol Hepatol 2010; 25:526.
- Gardner TB, Coelho-Prabhu N, Gordon SR, et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 2011; 73:718.
- Varadarajulu S, Bang JY, Sutton BS, et al. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology 2013; 145:583.
- Siddiqui AA, Dewitt JM, Strongin A, et al. Outcomes of EUS-guided drainage of debris-containing pancreatic pseudocysts by using combined endoprosthesis and a nasocystic drain. Gastrointest Endosc 2013; 78:589.
- Varadarajulu S, Lopes TL, Wilcox CM, et al. EUS versus surgical cyst-gastrostomy for management of pancreatic pseudocysts. Gastrointest Endosc 2008; 68:649.
- Park DH, Lee SS, Moon SH, et al. Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial. Endoscopy 2009; 41:842.
- Devière J, Bueso H, Baize M, et al. Complete disruption of the main pancreatic duct: endoscopic management. Gastrointest Endosc 1995; 42:445.
- Lawrence C, Howell DA, Stefan AM, et al. Disconnected pancreatic tail syndrome: potential for endoscopic therapy and results of long-term follow-up. Gastrointest Endosc 2008; 67:673.
- Arvanitakis M, Delhaye M, Bali MA, et al. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007; 65:609.
- Okabe Y, Tsuruta O, Kaji R, et al. Endoscopic retrieval of migrated plastic stent into bile duct or pancreatic pseudocyst. Dig Endosc 2009; 21:1.
- Bang JY, Wilcox CM, Trevino J, et al. Factors impacting treatment outcomes in the endoscopic management of walled-off pancreatic necrosis. J Gastroenterol Hepatol 2013; 28:1725.
- Baron TH, Thaggard WG, Morgan DE, Stanley RJ. Endoscopic therapy for organized pancreatic necrosis. Gastroenterology 1996; 111:755.
- Hariri M, Slivka A, Carr-Locke DL, Banks PA. Pseudocyst drainage predisposes to infection when pancreatic necrosis is unrecognized. Am J Gastroenterol 1994; 89:1781.
- Weckman L, Kylänpää ML, Puolakkainen P, Halttunen J. Endoscopic treatment of pancreatic pseudocysts. Surg Endosc 2006; 20:603.
- Gambiez LP, Ernst OJ, Merlier OA, et al. Arterial embolization for bleeding pseudocysts complicating chronic pancreatitis. Arch Surg 1997; 132:1016.
- Marshall GT, Howell DA, Hansen BL, et al. Multidisciplinary approach to pseudoaneurysms complicating pancreatic pseudocysts. Impact of pretreatment diagnosis. Arch Surg 1996; 131:278.
- Sahel J. Endoscopic drainage of pancreatic cysts. Endoscopy 1991; 23:181.
- Howell DA, Holbrook RF, Bosco JJ, et al. Endoscopic needle localization of pancreatic pseudocysts before transmural drainage. Gastrointest Endosc 1993; 39:693.
- Smith MT, Sherman S, Ikenberry SO, et al. Alterations in pancreatic ductal morphology following polyethylene pancreatic stent therapy. Gastrointest Endosc 1996; 44:268.
- Sherman S, Hawes RH, Savides TJ, et al. Stent-induced pancreatic ductal and parenchymal changes: correlation of endoscopic ultrasound with ERCP. Gastrointest Endosc 1996; 44:276.