Endoscopic management of pancreatic pseudocysts and necrosis

Abstract

Over the last several years, there have been refinements in the understanding and nomenclature regarding the natural history of acute pancreatitis. Patients with acute pancreatitis frequently develop acute pancreatic collections that, over time, may evolve into pancreatic pseudocysts or walled-off necrosis. Endoscopic management of these local complications of acute pancreatitis continues to evolve. Treatment strategies range from simple drainage of liquefied contents to repeated direct endoscopic necrosectomy of a complex necrotic collection. In patients with chronic pancreatitis, pancreatic pseudocysts may arise as a consequence of pancreatic ductal obstruction that then leads to pancreatic ductal disruption. In this review, we focus on the indications, techniques and outcomes for endoscopic therapy of pancreatic pseudocysts and walled-off necrosis.

Keywords:

• acute pancreatitis
• drainage/methods
• endoscopic therapy
• minimally invasive
• pancreatic necrosis/therapy
• pancreatitis/complications
• therapeutic irrigation

Author contributions

R Law, drafted the manuscript & approved the final manuscript. TH Baron contributed to the conception of article, critical review and final manuscript approval.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Pancreatic ductal injury frequently leads to formation of pancreatic fluid collections with or without solid necrotic debris.

• Endoscopic therapy is considered the current standard of care for management of symptomatic pancreatic collections.

• Cross-sectional imaging should be obtained prior to any endoscopic intervention to discern the size, location of anticipated access points and adjacent vascular structures.

• Drainage of pseudocysts or liquefied contents within a necrotic cavity can be performed with or without endoscopic ultrasound guidance. Large collections causing gastric outlet obstruction can be visualized endoscopically and drained with a standard forward-viewing gastroscope.

• Following initial drainage, cystgastrostomy/cystduodenostomy patency can be maintained using multiple double-pigtail plastic stents or a single self-expandable metal stent.

• Direct endoscopic necrosectomy can be performed using a variety of techniques, but remains a time-intensive endeavor.

• The two most common adverse events associated with endoscopic drainage of pancreatic collections are bleeding and perforation.