Endoscopic management of walled-off pancreatic fluid collections: Techniques
- 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 for a walled-off pancreatic fluid collection. 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 'Definitions' below.)
Overall, endoscopic management of walled-off pancreatic fluid collections is over 90 percent technically successful, with a 10 to 15 percent morbidity rate, a 70 to 80 percent resolution rate, and a 10 to 15 percent recurrence rate. The endoscopic approaches used for management of walled-off pancreatic fluid collections have been most successful in the setting of chronic pancreatitis (success rates over 90 percent), followed by acute pancreatitis (success rates over 70 percent) [1-6]. Success rates are lower if pancreatic necrosis is present because of higher rates of infectious complications and because solid debris is much more difficult to remove. Recurrence rates exceeding 30 percent have been observed in these settings [5,7]. (See "Endoscopic management of walled-off pancreatic fluid collections: Efficacy and complications", section on 'Efficacy'.)
This topic will review the endoscopic management of walled-off pancreatic fluid collections. The classification of pancreatic cysts, the diagnosis of walled-off pancreatic fluid collections, and the efficacy and complications of endoscopic management 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: Efficacy and complications".)
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"):
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- CHOICE OF DRAINAGE PROCEDURE
- PATIENT PREPARATION
- TRANSPAPILLARY STENT PLACEMENT
- ENDOSCOPIC TRANSMURAL DRAINAGE
- Puncture site localization and entering the fluid collection
- - Endoscopic ultrasonography
- - Endoscopic needle localization
- Fluid-collection puncture
- Cystenterostomy creation and stent placement
- - "Conventional" technique
- - Alternative techniques
- Management of biliary obstruction
- Combined transmural drainage and transpapillary stent placement
- Post-drainage care
- SUMMARY AND RECOMMENDATIONS