Endoscopic approach to pancreatic pseudocysts: An American perspective

Abstract

Pancreatic pseudocysts, abscesses, and walled-off pancreatic necrosis are types of pancreatic fluid colle ctions that arise as a consequence of pancreatic injury. Pain, early satiety, biliary obstruction, and infection are all indications for drainage. Percutaneous-radiologic drainage, surgical drainage, and endoscopic drainage are the three traditional approaches to the drainage of pancreatic pseudocysts. The endoscopic approach to pancreatic pseudocysts has evolved over the past thirty years and endoscopists are often capable of draining these collections. In experienced centers endoscopic ultrasound-guided endoscopic drainage avoids complications related to percutaneous drainage and is less invasive than surgery.

Triple Pancreatic Walled-off Fluid Collections Treated Simultaneously With Endoscopic Transmural Drainage

“…Pseudocysts or WOPN may lead to compression of surrounding structures, such as the stomach, duodenum, and common bile duct, leading to obstruction. Presence of symptoms (pain, early satiety), expansion of fluid collection, and complications (biliary obstruction, infection, rupture, hemorrhage) are indications for drainage [1,3]. These fluid collections should only be punctured when the wall has matured and after pseudoaneurysm has been ruled out by imaging [2].…”

“…Symptomatic PFCs can be drained by percutaneous, surgical, and endoscopic techniques [1,[3][4]. Endoscopic drainage can involve cyst gastrostomy, cyst duodenostomy, and transpapillary approaches.…”

“…No prospective randomized trials have been performed as of yet to compare the results of the three traditional approaches [3]. The choice of the approach depends on the general condition of the patient, the anatomic relationship of the collection to the stomach and duodenum, the size of the collection, and presence of communication of the pseudocyst with the pancreatic duct [1,3]. EUS-guided transmural drainage is less invasive than surgery and avoids complications related to percutaneous drainage; hence, it should be given the first preference [5].…”

“…Walled-off PFCs include pseudocysts and walled-off pancreatic necrosis (WOPN). The disruption of the pancreatic duct or side branches results in the collection of fluid that may or may not contain debris [1]. Pancreatic pseudocysts are PFCs surrounded by fibrous tissue without a lining of the epithelium.…”

“…Worsening of symptoms and expansion of fluid collections on imaging should prompt intervention [2]. Treatment of symptomatic patients includes percutaneous radiologic, surgical, and endoscopic drainage [1,[3][4]. Endoscopic drainage can involve cyst gastrostomy, cyst duodenostomy, and transpapillary approaches.…”