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"):To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- 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.
- 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.
- Giovannini M, Pesenti C, Rolland AL, et al. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts or pancreatic abscesses using a therapeutic echo endoscope. Endoscopy 2001; 33:473.
- Mani V, Cartwright K, Dooley J, et al. Antibiotic prophylaxis in gastrointestinal endoscopy: a report by a Working Party for the British Society of Gastroenterology Endoscopy Committee. Endoscopy 1997; 29:114.
- Howell DA, Holbrook RF, Bosco JJ, et al. Endoscopic needle localization of pancreatic pseudocysts before transmural drainage. Gastrointest Endosc 1993; 39:693.
- Fockens P, Johnson TG, van Dullemen HM, et al. Endosonographic imaging of pancreatic pseudocysts before endoscopic transmural drainage. Gastrointest Endosc 1997; 46:412.
- Grimm H, Binmoeller KF, Soehendra N. Endosonography-guided drainage of a pancreatic pseudocyst. Gastrointest Endosc 1992; 38:170.
- Savides TJ, Gress F, Sherman S, et al. Ultrasound catheter probe-assisted endoscopic cystgastrostomy. Gastrointest Endosc 1995; 41:145.
- Wiersema MJ. Endosonography-guided cystoduodenostomy with a therapeutic ultrasound endoscope. Gastrointest Endosc 1996; 44:614.
- Seifert H, Dietrich C, Schmitt T, et al. Endoscopic ultrasound-guided one-step transmural drainage of cystic abdominal lesions with a large-channel echo endoscope. Endoscopy 2000; 32:255.
- Varadarajulu S, Wilcox CM, Tamhane A, et al. Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage. Gastrointest Endosc 2007; 66:1107.
- Sanders MK, Aoun E. Experience with a Prototype Forward-Viewing Curvilinear Array Therapeutic Echoendoscope for Interventional EUS: A Case Series. Gastrointestinal Endoscopy 2010; 71:AB102.
- Kozarek RA. Endoscopic treatment of pancreatic pseudocysts. Gastrointest Endosc Clin N Am 1997; 7:271.
- Cremer M, Deviere J, Engelholm L. Endoscopic management of cysts and pseudocysts in chronic pancreatitis: long-term follow-up after 7 years of experience. Gastrointest Endosc 1989; 35:1.
- Shah RJ, Shah JN, Waxman I, et al. Safety and efficacy of endoscopic ultrasound-guided drainage of pancreatic fluid collections with lumen-apposing covered self-expanding metal stents. Clin Gastroenterol Hepatol 2015; 13:747.
- Itoi T, Binmoeller KF, Shah J, et al. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012; 75:870.
- Gornals JB, De la Serna-Higuera C, Sánchez-Yague A, et al. Endosonography-guided drainage of pancreatic fluid collections with a novel lumen-apposing stent. Surg Endosc 2013; 27:1428.
- Baron TH, Thaggard WG, Morgan DE, Stanley RJ. Endoscopic therapy for organized pancreatic necrosis. Gastroenterology 1996; 111:755.
- 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.
- Siddiqui AA, Easler J, Strongin A, et al. Hydrogen peroxide-assisted endoscopic necrosectomy for walled-off pancreatic necrosis: a dual center pilot experience. Dig Dis Sci 2014; 59:687.
- Abdelhafez M, Elnegouly M, Hasab Allah MS, et al. Transluminal retroperitoneal endoscopic necrosectomy with the use of hydrogen peroxide and without external irrigation: a novel approach for the treatment of walled-off pancreatic necrosis. Surg Endosc 2013; 27:3911.
- Giovannini M. EUS-guided pancreatic pseudocyst drainage. Tech Gastrointest Endosc 2007; 9:32.
- Gluck M, Ross A, Irani S, et al. Dual modality drainage for symptomatic walled-off pancreatic necrosis reduces length of hospitalization, radiological procedures, and number of endoscopies compared to standard percutaneous drainage. J Gastrointest Surg 2012; 16:248.
- Ahlawat SK, Charabaty-Pishvaian A, Jackson PG, Haddad NG. Single-step EUS-guided pancreatic pseudocyst drainage using a large channel linear array echoendoscope and cystotome: results in 11 patients. JOP 2006; 7:616.
- Jansen JM, Hanrath A, Rauws EA, et al. Intracystic wire exchange facilitating insertion of multiple stents during endoscopic drainage of pancreatic pseudocysts. Gastrointest Endosc 2007; 66:157.
- Barthet M, Sahel J, Bodiou-Bertei C, Bernard JP. Endoscopic transpapillary drainage of pancreatic pseudocysts. Gastrointest Endosc 1995; 42:208.
- 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.
- Binmoeller KF, Seifert H, Walter A, Soehendra N. Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 1995; 42:219.
- 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.
- 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.
- Yasuda I, Nakashima M, Iwai T, et al. Japanese multicenter experience of endoscopic necrosectomy for infected walled-off pancreatic necrosis: The JENIPaN study. Endoscopy 2013; 45:627.
- Rao R, Fedorak I, Prinz RA. Effect of failed computed tomography-guided and endoscopic drainage on pancreatic pseudocyst management. Surgery 1993; 114:843.
- Seifert H, Biermer M, Schmitt W, et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009; 58:1260.
- 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.
- 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.
- 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