Management of Inflammatory Fluid Collections and Walled-Off Pancreatic Necrosis

Abstract

Pancreatic fluid collections are a frequent complication of acute pancreatitis. The revised Atlanta criterion classifies chronic fluid collections into pseudocysts and walled-off pancreatic necrosis (WON). Symptomatic PFCs require drainage options that include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, minimally invasive endoscopic drainage has now become the preferred approach. An endoscopic ultrasonography (EUS)-guided approach for pancreatic fluid collection drainage is now the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WON. Direct endoscopic necrosectomy is often required in WON. Lumen apposing metal stents allow for direct endoscopic necrosectomy and debridement through the stent lumen and are now preferred in these patients. Endoscopic retrograde cholangiopancreatography with pancreatic duct exploration should be performed concurrent to PFC drainage in patients with suspected PD disruption. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Ideally, pancreatic ductal disruption should be bridged with endoscopic stenting.

Novel lumen‐apposing metal stent for the drainage of pancreatic fluid collections: An Italian multicentre experience

“…Another reported advantage of LAMSs compared to plastic stents is the possibility of performing DEN through the larger calibre of these stents, with associated minimal incidence of adverse events 2 , 3 , 11–14 . In our cohort, we performed DEN in 8 patients (12.1%).…”

“…The largest study evaluating the use of Nagi stents to date is, to our knowledge, the one by Lakhtakia et al, which evaluated its use in 205 WOPN patients with a technical success of 99% and an initial clinical success of 74.6%, which is lower compared to our results but with a lower rate of adverse events (3.9%). 14 18 19 Nagi 100% 100% Shah et al, 2015 13 33 Axios 91% 93% Huggett et al, 2015 17 19 15 reporting that technical success was 100% and that final clinical success was 100%. Nevertheless, compared to our study, Mukai et al also positioned a nasocystic tube in 28.6% of their patients in order to perform lavages of the cavity, which could explain their higher clinical success rate.…”

“…25 Another reported advantage of LAMSs compared to plastic stents is the possibility of performing DEN through the larger calibre of these stents, with associated minimal incidence of adverse events. 2,3,[11][12][13][14] In our cohort, we performed DEN in 8 patients (12.1%). The low rate of DEN required, compared to other studies using different LAMSs, 3 was probably due to the efficient drainage through these wide-calibre metal stents.…”

Managing Acute Severe Necrotising Pancreatitis

“…Delay in the intervention (approx. 3-5 weeks) allows the necrotic tissue to become liquified and more defined (walled-off), which makes removal easier and more complete [15,30,31]. Lower major complications (45% vs 73%, p<0.001) and mortality (10% vs 33%, p=0.002) for the step-up group.…”

“…A flexible endoscope is passed transorally and then transmurally to perform a puncture of either the stomach or duodenum wall, to gain access to the necrosis [54,55]. Usually multiple procedures are needed to achieve a full debridement using this approach [30,34]. This method has been compared to other necrosectomy techniques and has, similarly to VARD, allowed for a reduction of major complications when compared with open necrosectomy.…”