Endoscopic management of pancreatic fluid collections

Abstract

Acute pancreatitis is an acute inflammatory process of the pancreas which presents with severe epigastric abdominal pain along with at least a 3-fold increase in the serum lipase. It is one of the most common gastroenterology discharge diagnoses and costs an estimated $2.6 billion annually (1). Acute pancreatitis is classified as either interstitial edematous pancreatitis or necrotizing pancreatitis. Pancreatic fluid collections (PFCs) are common complications of acute pancreatitis, and are characterized based on the revised Atlanta classification (Table 1). There are four subtypes of PFCs: acute peripancreatic fluid collections, acute necrotic collections, pseudocysts, and walled-off necrosis (WON). These collections are differentiated based on duration (less than or greater than 4 weeks from onset of acute pancreatitis) and presence or absence of necrosis. Interstitial edematous pancreatitis can lead to acute peripancreatic fluid collections (<4 weeks) or pancreatic pseudocysts (>4 weeks). Necrotizing pancreatitis can lead to acute necrotic collections (<4 weeks) and WON (>4 weeks) (2).A 2018 study evaluated the outcomes of acute pancreatic and peripancreatic collections that occur in patients with acute pancreatitis. The study demonstrated that the majority of patients that present with interstitial edematous pancreatitis will not develop pseudocysts. This was in contrast to patients who initially present with necrotizing pancreatitis. Of these patients, 93.4% developed acute necrotic collections. Of those that survived, 70% of the acute necrotic collections developed into walled off necrosis (3).The management of peripancreatic fluid collections has evolved with time. Most acute peripancreatic fluid collections or acute necrotic collections do not require any intervention as they may improve with conservative management. Conservative management usually entails antibiotics and nutritional support. Asymptomatic pseudocysts and WON also do not require any intervention as they may resolve on their own. If a patient is symptomatic from their pancreatic fluid collection, then it may need to be drained. Symptoms may include persistent abdominal pain, fevers, early satiety, nausea and vomiting, inability to tolerate diet, and concern for infection.Draining symptomatic collections can be accomplished surgically, percutaneously, or endoscopically. Many studies have looked at the optimal approach for management.

A narrative review of acute pancreatitis and its diagnosis, pathogenetic mechanism, and management

“…When AFC persists beyond 4 weeks, there is the possibility of surrounding fibrous tissue forming a pseudocyst, with a round or ellipse shape; enlargement of the cyst may cause symptoms of compression, while infection of the cyst can induce an inflammatory response (162). For a pancreatic pseudocyst with an immature cystic wall, conservative therapy is generally recommended, including the use of antibiotics, physiotherapy, and r e g u l a r f o l l o w -u p e x a m i n a t i o n u s i n g a b d o m i n a l ultrasound, enhanced CT, and MR imaging (163). For pseudocysts >6 cm that persist for >6 weeks, surgical or endoscopic intervention is recommended when symptomatic, as the cyst wall is mature and, thus, cannot resolve spontaneously (164,165).…”

Endoscopic transmural drainage and necrosectomy in acute necrotizing pancreatitis: A review

“…Their characteristics and associated adverse events are listed in Table 1. [38][39][40][41][42][43][44][45][46][47][48] These three types of stents are used extensively in practice. There have been limited studies comparing their clinical efficacy and safety, and produced inconsistent results, leaving stent selection a contentious topic.…”

“…Traditionally, PSs are used for PFC transmural drainage, which has achieved good results for pseudocysts. However, these were less effective for more complex PFCs, such as WOPN, [39] which is thought to be because of their small diameter which can be easily occluded by necrotic debris, Metal stents (FCSEMS and LAMS) with wider diameter overcome the problem of draining high consistency liquid and are used mainly in the drainage of WOPN. They can be placed under EUS only without fluoroscopy.…”

Pancreatitis aguda. Manejo endoscópico

“…Posteriormente se inserta una guía hidrofílica 0.035 por la aguja hasta la colección líquida y se retira la aguja, dejando la guía en la colección. Posteriormente se necesita crear una fístula mediante la utilización de un cistostomo y ampliarla con un balón dilatador, posteriormente se procede a colocación de la prótesis (Figura 1) 11 .…”