Pancreatic duct (PD) strictures, leaks, and disconnected ducts are important morphologic consequences of inflammatory disease of the pancreas, resulting in abdominal pain, pancreatic ascites, pancreatic pleural effusion, and external pancreatic fistula. Traditionally, these PD complications were treated surgically, but a better understanding of their pathophysiology, along with advancement in endoscopic interventions, has transformed the therapy from morbid surgical interventions to minimally invasive, safe, and effective endoscopic treatment. This review discusses the current diagnostic and management strategies for PD strictures, leaks, and disconnected pancreatic ducts.

Postoperative pancreatic fistula (POPF) remains a common and dreaded complication after pancreatic resections and is associated with increased morbidity and mortality. Over the years, several different strategies have been investigated to prevent and mitigate POPF. However, when a POPF occurs, a consensus on the optimal management strategy of grade B and grade C POPF is still lacking, and the current management strategy is often based on local expertise and driven by patient's condition. Nevertheless, whereas the incidence of POPF after pancreatic surgery has remained stable, the overall mortality related to this complication has decreased over the years. This reflects an improvement in the management of this complication, which has become increasingly conservative. The aim of this review is to provide an updated evidence-based overview on the management strategies of POPF for surgeons and physicians in the clinical practice.

Endoscopic transmural drainage (ETD) using double-pigtail stents (DPSs) is a well-established treatment for walled-off pancreatic necrosis (WON). This study aimed to compare outcomes in patients undergoing ETD with DPSs left indwelling versus those where stents were removed or migrated.

This retrospective multicenter cohort study included patients with WON who underwent ETD using DPSs between July 2001 and December 2019. The primary outcome was recurrence of a pancreatic fluid collection (PFC). Secondary outcomes were long-term complications and recurrence-associated factors. Competing risk regression analysis considered DPS removal or migration as time-varying covariates.

Among 320 patients (median age 58; 36% women), DPSs were removed in 153 (47.8%), migrated spontaneously in 27 (8.4%), and remained indwelling in 140 (43.8%). PFC recurrence was observed in 57 patients (17.8%): after removal (n = 39; 25.5%); after migration (n = 4; 14.8%); in patients with indwelling DPSs (n = 14; 10.0%). In 25 patients (7.8%), drainage of recurrent PFC was indicated. Risk factors for recurrence were DPS removal or migration (hazard ratio [HR] 3.45, 95%CI 1.37-8.70) and presence of a disconnected pancreatic duct (HR 5.08, 95%CI 1.84-14.0).

Among patients who undergo ETD of WON, leaving DPSs in situ seems to lower the risk of recurrent fluid collections, without any long-term DPS-related complications. These results suggest that DPSs should not be routinely removed and can be safely left indwelling indefinitely.

Lumen-apposing metal stents (LAMS) are preferred to initial drainage in pancreatic fluid collections (PFCs) patients with disconnected pancreatic duct syndrome (DPDS) in recent years. However, unlike plastic stents, the long-term placement of LAMS is not recommended due to a high risk of local complications. This meta-analysis attempted to evaluate the effect of using plastic stents for prolonged drainage after LAMS removal on recurrence of PFCs in DPDS.

A comprehensive literature search was conducted from inception until January 2023, to identify articles investigating the endoscopic ultrasound (EUS)-guided treatment of plastic stents compared with no plastic stents following LAMS removal in patients with PFCs and DPDS. The primary outcome measures included recurrence of PFCs and need for reintervention.

We identified 3 eligible articles including 520 patients with PFCs, 246 of whom with DPDS. There was a total of 143 and 103 patients in the plastic stents group and in the no plastic stents group, respectively. The plastic stents group exhibited a lower rate of PFCs recurrence following LAMS removal after PFCs resolution compared with the no plastic stents group (OR 0.15; 95% CI 0.03-0.75; P =0.02). However, there was no difference in the rates of reintervention between the two groups (OR 0.52; 95% CI 0.15-1.83; P =0.31). There was no severe adverse events and mortality associated with stent placement or exchange in all patients.

Deployment of plastic stents for long-term drainage after LAMS replacement can decrease the risk of PFCs recurrence in patients with DPDS following resolution, but it does not impact reintervention rates.

Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40 % of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past few years the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques such as endoscopic ultrasound-guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group, Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) are intended to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.

Pancreatic fluid collections (PFCs) may recur after resolution with endoscopic transmural drainage (ETD) and standard stent removal (SSR). Herein, we compared the efficacy and safety of leaving long-term indwelling plastic stents (LTIS) vs. standard stent removal after PFC resolution with ETD.

We performed a systematic review of MEDLINE, EMBASE, CINAHL, Scopus, and Cochrane databases from inception to September 2022. Full-text articles comparing long-term (> 6 months) outcomes of LTIS and SSR were eligible, as well as single-arm studies with ≥ 10 patients with LTIS. Two independent reviewers selected studies, extracted data, and assessed the risk of bias using the Newcastle-Ottawa Scale. Measured outcomes included the following: (A) PFC recurrence; (B) interventions for PFC recurrence; (C) technical success; and (D) adverse events (AEs). Meta-analysis was carried out using random-effects models.

We included 16 studies, encompassing 1285 patients. Compared to SSR after PFC resolution with ETD, LTIS was associated with significantly lower risk of PFC recurrence (3% vs. 23%; OR 0.22 [95%CI 0.09-0.52]; I2 = 45%) and need for interventions (2% vs. 14%; OR 0.35 [95%CI 0.16-0.78]; I2 = 0%). The superiority of LTIS on reducing PFC recurrence was found with walled-off necrosis, with or without disconnected pancreatic duct, and with placement of ≥ 2 LTIS. When using LTIS, the pooled proportion of AEs was 8% (95%CI 4-11%) and technical success was 93% (95%CI 86-99%).

Our results show that LTIS after PFC resolution with ETD is feasible, safe, and superior to SSR in reducing the risk of PFC recurrence and need for interventions.

Video 1Demonstration of the endoscopic technique of leaving long-term indwelling plastic stent(s) when a lumen-apposing metal stent is removed after pancreatic fluid collection resolution.

Replacing lumen apposing metal stents (LAMS) with permanent indwelling plastic stents after the resolution of pancreatic fluid collections (PFC) in patients with disconnected pancreatic duct (DPD) is a debatable issue. We retrospectively evaluated the safety and efficacy of replacing LAMS with long-term indwelling transmural plastic stents in patients with DPD at head/neck of pancreas.

The database of patients with PFC who underwent endoscopic transmural drainage with LAMS over the last three years was retrospectively analyzed to identify patients with DPD at the level of the head/neck of the pancreas. The patients were divided into two groups: Group A where LAMS could be replaced with plastic stents and Group B, where LAMS could not be replaced with plastic stents. The two groups were compared for recurrence of symptoms/PFC and complications.

Out of 53 patients studied, 39 patients (34 males; mean age: 35.7 ± 6.6 years) were included in Group A and 14 patients in Group B (11 males; mean age: 33.4 ± 5.9 years). The demographic profile as well as indwelling time of LAMS was comparable between two groups. PFC recurrence was observed in 2/39 (5.1%) patients in group A and 6/14 (42.8%) patients in group B (p = 0.0001) with one patient in group A and 5 patients in group B requiring repeat intervention for recurrent PFC.

Long-term transmural plastic stent placement after removal of LAMS in pancreatic duct disconnection at head/neck of the pancreas is safe and effective strategy to prevent the recurrence of PFC.

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.

Disconnected pancreatic duct syndrome (DPDS) is an important and common complication of acute necrotizing pancreatitis. Endoscopic approach has been established as the first-line treatment for pancreatic fluid collections (PFCs) with less invasion and satisfactory outcome. However, the presence of DPDS significantly complicates the management of PFC; besides, there is no standardized treatment for DPDS. The diagnosis of DPDS presents the first step of management, which can be preliminarily established by imaging methods including contrast-enhanced computed tomography, ERCP, magnetic resonance cholangiopancreatography (MRCP), and EUS. Historically, ERCP is considered as the gold standard for the diagnosis of DPDS, and secretin-enhanced MRCP is recommended as an appropriate diagnostic method in existing guidelines. With the development of endoscopic techniques and accessories, the endoscopic approach, mainly including transpapillary and transmural drainage, has been developed as the preferred treatment over percutaneous drainage and surgery for the management of PFC with DPDS. Many studies concerning various endoscopic treatment strategies have been published, especially in the recent 5 years. Nonetheless, existing current literature has reported inconsistent and confusing results. In this article, the latest evidence is summarized to explore the optimal endoscopic management of PFC with DPDS.

Necrotizing pancreatitis may result in a disrupted or disconnected pancreatic duct (DPD) with the potential for long lasting negative impact on a patient's clinical outcome. There is a lack of detailed data on the full clinical spectrum of DPD which is critical for the development of better diagnostic and treatment strategies.

We performed a long-term post-hoc analysis of a prospectively collected nationwide cohort of 896 patients with necrotizing pancreatitis (2005-2015). The median follow-up after hospital admission was 75 months (P25-P75:41-151). Clinical outcomes of patients with and without DPD were compared using regression analyses, adjusted for potential confounders. Predictive features for DPD were explored.

DPD was confirmed in 243 (27%) of the 896 patients and resulted in worse clinical outcomes during both the patient's initial admission and follow-up. During hospital admission, DPD was associated with an increased rate of new-onset intensive care unit admission (adjusted-OR2.52 [95%-CI 1.62-3.93]), new-onset organ failure (adjusted-OR2.26 [95%-CI 1.45-3.55]), infected necrosis (adjusted-OR4.63 [95%-CI 2.87-7.64]) and pancreatic interventions (adjusted-OR7.55 [95%-CI 4.23-13.96]). During long-term follow-up, DPD increased the risk of pancreatic intervention (adjusted-OR9.71 [95%-CI 5.37-18.30], recurrent pancreatitis (adjusted-OR2.08 [95%-CI 1.32-3.29]), chronic pancreatitis (adjusted-OR2.73 [95%-CI 1.47-5.15]) and endocrine pancreatic insufficiency (adjusted-OR1.63 [95%-CI 1.05-2.53]).Central or subtotal pancreatic necrosis on computed tomography (CT), (OR9.49 [95%-CI 6.31-14.29] and a high levels of serum C-reactive protein (CRP) in the first 48 hours after admission (per 10 points increase, OR1.02 [95%-CI 1.00-1.03] were identified as independent predictors for developing DPD.

At least one of every four patients with necrotizing pancreatitis suffer from DPD which is associated with detrimental, short and long-term interventions and complications. Central and subtotal pancreatic necrosis and high levels of serum CRP in the first 48 hours are independent predictors for DPD.

Disconnected pancreatic duct (DPD) after development of walled-off necrosis (WON) predisposes to recurrent (peri)pancreatic fluid collection (PFC). In this randomized controlled trial, we compared plastic stents with no plastic stent after removal of a large-caliber metal stent (LCMS) on incidence of recurrent PFCs in DPD. METHODS : Consecutive patients with WON who underwent endoscopic ultrasound (EUS)-guided drainage with LCMS between September 2017 and March 2020 were screened for eligibility. At LCMS removal (4 weeks after drainage), patients with DPD were randomized to plastic stent or no stent groups. The primary outcome was incidence of recurrent PFC at 3 months. Secondary outcomes were technical success of plastic stent deployment, adverse events, stent migration, and recurrence of PFC at 6 and 12 months.

236 patients with WON underwent EUS-guided drainage using LCMS, and 104 (males 94, median age 34 years (interquartile range [IQR] 26-44.7) with DPD were randomized into stenting (n = 52) and no-stenting (n = 52) groups. Plastic stent deployment was successful in 88.5 %. Migration occurred in 19.2 % at median follow-up of 8 months (IQR 2.5-12). Recurrent PFCs occurred in six patients at 3 months (stent n = 3, no stent n = 3). There was no significant difference in PFC recurrence between the two groups at 3, 6, and 12 months. Reintervention was required in seven patients with recurrent PFCs, with no significant difference between the two groups.

In patients with WON and DPD, deployment of plastic stents after LCMS removal did not reduce recurrence of PFC.

Clinically significant ascites in acute pancreatitis (AP) is rarely encountered and is a result of multifactorial pathogenesis. Early reactionary ascites in AP usually does not require any treatment and resolves spontaneously in majority of patients. A diagnostic analysis should be performed in case of ascites developing in the latter stages with increasing pain or worsening organ failure. Low serum albumin-ascites gradient ascites with amylase > 1000 U/l is highly suggestive of pancreatic ascites that is usually associated with duct disruption. A combination of nasojejunal feeding, subcutaneous octreotide, endoscopic drainage and rarely, surgery are employed in managing this difficult to treat condition. There is a need of further studies to better understand the clinical role of ascites as well as contribution of other factors like hypoalbuminemia and portal hypertension to its development in AP.

The review is devoted to diagnosis and treatment of disconnected pancreatic duct syndrome (DPDS) in patients with acute pancreatitis. Data on terminology, indications and options for endoscopic transluminal interventions are presented in detail. The results of numerous studies evaluating clinical efficacy of various endoscopic and open surgical procedures are analyzed. Available data confirm advisability of staged treatment of DPDS with primary endoscopic drainage of pancreatic fluid accumulations in specialized centers.

Long-term transmural double-pigtail stent (DPS) placement is recommended for patients with disconnected pancreatic duct syndrome (DPDS) and peripancreatic fluid collections (peri-PFCs). The long-term safety and efficacy of indwelling DPSs were evaluated.

Medical files of patients treated with DPS for DPDS-associated peri-PFC and with a follow-up ≥ 48 months were reviewed. Early ( < 30 days) and late complications of DPS placement were evaluated and the primary endpoint, i. e., incidence of late complications per 100 patient-years of follow-up, was calculated. Short- and long-term success rates of endoscopic treatment and rate of peri-PFC recurrence were among secondary endpoints.

From 2002 to 2014 we identified 116 patients, with mean (SD) follow-up of 80.6 (34.4) months. Among early complications (n = 20), 6 occurred peri-interventionally. Late complications (n = 17) were mainly pain due to DPS-induced ulcer or erosion (n = 10) and 14 of these were treated conservatively or by stent removal; 2 gastro-pancreatico-colo-cutaneous fistulas and 1 persisting bleed required surgical intervention. No DPS-related deaths were recorded. The incidence rate (95 %CI) of late complications was 2.18 (1.27-3.49) per 100 patient-years of follow-up. Short- and long-term success rates (with 95 %CI) of endoscopic treatment were 97.4 % (94.5 %-100 %) and 94 % (89.6 %-98.3 %), respectively. The peri-PFC recurrence rate was 28 % (20.1 %-35.9 %), and 92.3 % of these occurred within the first 2 years. Stent migration, chronic pancreatitis, and length of stent (> 6 cm) were independently associated with higher rates of peri-PFC recurrence.

Long-term transmural drainage with DPS is a safe and effective treatment for DPDS-associated peri-PFCs. However, about one quarter of peri-PFCs will recur.

The review is devoted to endoscopic transluminal interventions in the treatment of acute necrotizing pancreatitis. Terminology, indications and options for transluminal drainage procedures and endoscopic sequestrectomy are presented in detail. The authors analyzed the results of numerous studies devoted to effectiveness of endoscopic interventions and possible combination of treatment options. Modern international clinical guidelines indicating the feasibility of endoscopic treatment of acute necrotizing pancreatitis in multi-field specialized centers are considered.

Severe pancreatitis may result in a disrupted pancreatic duct, which is associated with a complicated clinical course. Diagnosis of a disrupted pancreatic duct is not standardized in clinical practice or international guidelines. We performed a systematic review of the literature on imaging modalities for diagnosing a disrupted pancreatic duct in patients with acute pancreatitis.

A systematic search was performed in PubMed, Embase and Cochrane library databases to identify all studies evaluating diagnostic modalities for the diagnosis of a disrupted pancreatic duct in acute pancreatitis. All data regarding diagnostic accuracy were extracted.

We included 8 studies, evaluating five different diagnostic modalities in 142 patients with severe acute pancreatitis. Study quality was assessed, with proportionally divided high and low risk of bias and low applicability concerns in 75% of the studies. A sensitivity of 100% was reported for endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. The sensitivity of magnetic resonance cholangiopancreatography with or without secretin was 83%. A sensitivity of 92% was demonstrated for a combined cohort of secretin-magnetic resonance cholangiopancreatography and magnetic resonance cholangiopancreatography. A sensitivity of 100% and specificity of 50% was found for amylase measurements in drain fluid compared with ERCP.

This review suggests that various diagnostic modalities are accurate in diagnosing a disrupted pancreatic duct in patients with acute pancreatitis. Amylase measurement in drain fluid should be standardized. Given the invasive nature of other modalities, secretin-magnetic resonance cholangiopancreatography or magnetic resonance cholangiopancreatography would be recommended as first diagnostic modality. Further prospective studies, however, are needed.

Disconnected Pancreatic Duct Syndrome (DPDS) is an important but often overlooked complication of acute necrotising pancreatitis (ANP) that occurs due to necrosis of the main pancreatic duct (PD). This segmental necrosis leads on to disconnection between the viable upstream pancreatic parenchyma and the duodenum. The disconnected and functional segment of pancreas continues to secrete pancreatic juice that is not drained into the gastrointestinal tract and lead on to recurrent pancreatic fluid collections (PFC), refractory external pancreatic flstulae and chronic abdominal pain/recurrent pancreatitis. Because of lack of awareness of this important complication of ANP, the diagnosis of DPDS is usually delayed. The delay in diagnosis increases the morbidity of the disease as well as increase the cost of treatment and duration of hospital stay. Surgery has remained the cornerstone for management of patients with DPDS. The conventional surgical approaches have been either resection or internal drainage procedures. Surgery for DPDS in the setting of ANP is often difficult due to presence of local inflammation and extensive venous collaterals in the operative field due to splenic vein thrombosis and therefore is associated with significant morbidity. Advancement in therapeutic endoscopy, especially advent of therapeutic endoscopic ultrasound has opened an exciting new field of minimally invasive therapeutic options for management of DPDS. The present review discusses the current understanding of the clinical manifestations, imaging features and management strategies in patients with DPDS.

Lumen-apposing metal stents (LAMS) were considered a breakthrough in the endoscopic management of walled-off necrosis (WON), as their larger drainage diameter was expected to provide effective drainage of necrotic material. However, various studies and meta-analyses that have compared plastic and metal stents for the treatment of WON have shown conflicting results. We retrospectively compared the efficacy and safety of endoscopic transmural drainage between multiple plastic stents and LAMS.

Endoscopic data were retrospectively retrieved for patients who had undergone endoscopic ultrasound (EUS)-guided drainage/debridement of WON. Patients were divided into 2 groups according to whether multiple plastic stents or LAMS were deployed during initial drainage. The resolution and complication rates were compared between the 2 groups.

One hundred sixty-six patients (83% male, mean age 37.5 years) with symptomatic WON were treated with EUS-guided drainage using either multiple plastic stents (n=138) or LAMS (n=28). Patients in the LAMS group had significantly larger WON and a significantly higher proportion of solid content. WON resolution rates did not differ between plastic stents and LAMS (98.5% vs. 96.4% respectively, P=0.42). However, the time taken to resolution was significantly shorter in the LAMS group than in the plastic stents group (26.7 vs. 29.8 days, P=0.03). There was no significant difference between the groups in either mortality or complication rates.

The technical success, rates of WON resolution and complications were similar in patients treated with multiple plastic stents and LAMS. However, LAMS were associated with a significantly shorter time to resolution.

The last decade has seen a dramatic paradigm shift for the treatment of pancreatitis and its related complications away from surgery to minimally invasive endoscopic approaches. In this review, we provide an overview of the indications, techniques and outcomes of endoscopic interventions in the management of acute and chronic pancreatitis. Emphasis is placed on drainage of pancreatic pseudocysts and treatment of pain in chronic pancreatitis.

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition.

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis. BEST PRACTICE ADVICE 1: Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center. BEST PRACTICE ADVICE 2: Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended. BEST PRACTICE ADVICE 3: When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography-guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases. BEST PRACTICE ADVICE 4: In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated. BEST PRACTICE ADVICE 5: Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. BEST PRACTICE ADVICE 6: Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication. BEST PRACTICE ADVICE 7: Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula. BEST PRACTICE ADVICE 8: Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden. BEST PRACTICE ADVICE 9: Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis. BEST PRACTICE ADVICE 10: The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup. BEST PRACTICE ADVICE 11: Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity. BEST PRACTICE ADVICE 12: Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources. BEST PRACTICE ADVICE 13: Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures. BEST PRACTICE ADVICE 14: For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting. BEST PRACTICE ADVICE 15: A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise.

Necrotizing pancreatitis may lead to loss of integrity of the pancreatic duct, resulting in leakage of pancreatic fluid. Pancreatic duct disruption or disconnection is associated with a prolonged disease course and particular complications. Since a standard treatment for this condition is currently lacking, we performed a systematic review of the literature to compare outcomes of various treatment strategies.

A systematic review was performed according to the PRISMA guidelines in the PubMed, EMBASE and Cochrane databases. Included were articles considering the treatment of patients with disrupted or disconnected pancreatic duct resulting from acute necrotizing pancreatitis.

Overall, 21 observational cohort studies were included comprising a total of 583 relevant patients. The most frequently used treatment strategies included endoscopic transpapillary drainage, endoscopic transluminal drainage, surgical drainage or resection, or combined procedures. Pooled analysis showed success rates of 81% (95%-CI: 60-92%) for transpapillary and 92% (95%-CI: 77-98%) for transluminal drainage, 80% (95%-CI: 67-89%) for distal pancreatectomy and 84% (95%-CI: 73-91%) for cyst-jejunostomy. Success rates did not differ between surgical procedures (cyst-jejunostomy and distal pancreatectomy (risk ratio = 1.06, p = .26)) but distal pancreatectomy was associated with a higher incidence of endocrine pancreatic insufficiency (risk ratio = 3.06, p = .01). The success rate of conservative treatment is unknown.

Different treatment strategies for pancreatic duct disruption and duct disconnection after necrotizing pancreatitis show high success rates but various sources of bias in the available studies are likely. High-quality prospective, studies, including unselected patients, are needed to establish the most effective treatment in specific subgroups of patients, including timing of treatment and long-term follow-up.

The incidence of acute pancreatitis continues to increase worldwide, and it is one of the most common gastrointestinal causes for hospital admission in the USA. In the past decade, substantial advancements have been made in our understanding of the pathophysiological mechanisms of acute pancreatitis. Studies have elucidated mechanisms of calcium-mediated acinar cell injury and death and the importance of store-operated calcium entry channels and mitochondrial permeability transition pores. The cytoprotective role of the unfolded protein response and autophagy in preventing sustained endoplasmic reticulum stress, apoptosis and necrosis has also been characterized, as has the central role of unsaturated fatty acids in causing pancreatic organ failure. Characterization of these pathways has led to the identification of potential molecular targets for future therapeutic trials. At the patient level, two classification systems have been developed to classify the severity of acute pancreatitis into prognostically meaningful groups, and several landmark clinical trials have informed management strategies in areas of nutritional support and interventions for infected pancreatic necrosis that have resulted in important changes to acute pancreatitis management paradigms. In this Review, we provide a summary of recent advances in acute pancreatitis with a special emphasis on pathophysiological mechanisms and clinical management of the disorder.

Long-term transmural stent placement is a safe and effective strategy for the prevention of recurrence of pancreatic fluid collection in patients with walled-off necrosis and disconnected pancreatic duct syndrome. The presence of a stent for an indefinite period has been shown to be safe without any serious adverse effects. We report a rare case of pancreatic parenchymal calcification induced by long-term transmural stent.

Endoscopic transmural drainage is performed for symptomatic peripancreatic fluid collections (PPFCs). Long-term transmural double-pigtail stent (DPS) placement is useful in preventing recurrences. There are few reports on the long-term safety of DPS placement. Thus, this study aimed to examine the complications of long-term indwelling DPS for PPFCs.

Among 53 patients who underwent endoscopic ultrasound-guided transmural drainage for symptomatic PPFCs between April 2006 and March 2017, those followed up for over one year were included. Complications of long-term indwelling DPS were examined retrospectively.

This study enrolled 36 patients [30 men, median age 54 years (range 22-82)]. Walled-off necrosis was present in 22 cases (including 9 disconnected pancreatic duct syndrome cases) and pancreatic pseudocysts, in 14 cases. The median stenting period was 20.9 (range 0.8-142.3) months, and median observation period was 56.2 (range 12.4-147.1) months. Colon perforation due to DPS occurred in 3 cases (8.3%), at 5.8, 17.1, and 33.7 months after indwelling DPS placement; 2 cases developed perforation from the serosal side. In 1 case, the patient was treated surgically, and in 2 cases, the patients underwent endoscopic removal of the stent and showed improvement with conservative treatment.

Long-term indwelling transmural DPS for symptomatic PPFCs poses a risk of intestinal perforation. Thus, if possible, it may be better to avoid long-term placement.

External pancreatic fistulae (EPF) developing in setting of disconnected pancreatic duct syndrome (DPDS) are associated with significant morbidity and surgery is the only effective treatment.

To describe safety and efficacy of various endoscopic including endoscopic ultrasound (EUS) guided drainage techniques for resolving EPF in DPDS.

Retrospective analysis of data base of 18 patients (15 males; mean age: 37.6 ± 7.1years) with EPF and DPDS who were treated with various endoscopic techniques including EUS guided transmural drainage.

EPF developed post percutaneous drainage (PCD) (n = 15) or post-surgical necrosectomy (n = 3) of acute necrotic collections. All patients had refractory EPF with daily output of >50 ml/day with mean duration being 19.2 ± 6.1 weeks. One patient had failed surgical fistulo-jejunostomy. Various endoscopic techniques used were: transmural placement of pigtail stent through gastric opening of trans-gastric PCD (n = 5), EUS guided transmural puncture of fluid collection created by clamping PCD (n = 5) or by instillation of water though PCD (n = 3), direct EUS-guided puncture of fistula tract (n = 1) and EUS guided pancreaticogastrostomy (n = 4). EPF healed in 17/18 (94%) patients within 5-21 days and there has been no recurrence over follow up of 16.7 ± 12.8 weeks. Asymptomatic spontaneous external migration of stents was observed in 5/18 (29.4%) patients.

Management of refractory EPFs in setting of DPDS is challenging. In our experience, combination of various endoscopic techniques including EUS guided transmural drainage appears to be safe and effective treatment modality for treating these complex EPF's. However, further studies to identify patient selection and best treatment approaches are needed.

The incidence of acute pancreatitis continues to rise, inducing substantial medical and social burden, with annual costs exceeding $2 billion in the United States alone. Although most patients develop mild pancreatitis, 20% develop severe and/or necrotizing pancreatitis, requiring advanced medical and interventional care. Morbidity resulting from local and systemic complications as well as invasive interventions result in mortality rates historically as high as 30%. There has been substantial evolution of strategies for interventions in recent years, from open surgery to minimally invasive surgical and endoscopic step-up approaches. In contrast to the advances in invasive procedures for complications, early management still lacks curative options and consists of adequate fluid resuscitation, analgesics, and monitoring. Many challenges remain, including comprehensive management of the entire spectrum of the disease, which requires close involvement of multiple disciplines at specialized centers.

Walled of pancreatic necrosis (WOPN) is a new term coined for encapsulated fluid collection developing after acute necrotising pancreatitis (ANP). It is a heterogeneous collection containing varying amount of liquid as well as solid necrotic material. The literature on its natural history as well as appropriate management is gradually expanding thereby improving treatment outcomes of this enigmatic disease. Areas covered: This review discusses currently available literature on etiology, frequency, natural history, and imaging features WOPN. Also, updated treatment options including endoscopic, radiological and surgical drainage are discussed. Expert opinion: WOPN is alocal complication of ANP occurring in the delayed phase of ANP and may be asymptomatic (50%) or present with pain, fever, jaundice, or gastric outlet obstruction. Natural courses of asymptomatic WOPN have been infrequently studied, and it appears that the majority remain asymptomatic and resolve spontaneously. Magnetic resonance imaging and endoscopic ultrasound are the best imaging modalities to evaluate solid necrotic debris. Symptomatic WOPN usually needs immediate drainage, this can be done endoscopically, radiologically, or surgically. Current evidence suggests that endoscopic transluminal drainage is the preferred drainage technique as it is effective and associated with lower mortality, risk of organ failure, adverse effects, and length of hospital stay.

Acute necrotizing pancreatitis (ANP) can be associated with pancreatic duct (PD) disruption. PD disruption can lead to the formation of internal fistulae and consequent pancreatic ascites. Pancreatic ascites is reported very rarely following ANP, and therefore, the role of endotherapy in this setting is not defined. To retrospectively study the safety and efficacy of endoscopic drainage in patients with pancreatic ascites following ANP.

Over a period of 6 years, 12 patients (10 males; mean age: 35.9 ± 7.1 years) with pancreatic ascites following ANP underwent an attempted endoscopic drainage. Patients with a coexistent pancreatic fluid collection (PFC) underwent endoscopic ultrasound (EUS)-guided transmural drainage of PFC whereas patients with pancreatic ascites alone underwent transpapillary drainage alone.

Nine (75%) patients had coexistent PFC, whereas three patients presented with ascites only. The mean size of PFC was 7.2 ± 1.6 cm. Patients with PFC underwent successful EUS-guided transmural drainage (multiple plastic stents in eight and metal stent in one patient) with complete resolution of PFC as well as ascites within 2-3 weeks. Of three patients with ascites alone, one patient had complete PD disruption, whereas two patients had partial PD disruption. Both patients with partial disruption underwent successful placement of bridging transpapillary stent and resolution of ascites at 6 weeks. In patients with complete disruption, a nonbridging stent was placed into the disruption, and ascites resolved after 8 weeks. There has been no recurrence over 27.5 ± 17.7 weeks.

Endoscopic drainage is a safe and effective treatment modality for the treatment of pancreatic ascites following ANP.

Acute pancreatitis is a frequent, nonmalignant gastrointestinal disorder leading to hospital admission. For its severe form and subsequent complications, minimally invasive and endoscopic procedures are being used increasingly, and are subject to rapid technical advances. Areas covered: Based on a systematic literature search in PubMed, medline, and Web-of-Science, we discuss the currently available treatment strategies for endoscopic therapy of pancreatic pseudocysts, walled-off pancreatic necrosis (WON), and disconnected pancreatic duct syndrome (DPDS), and compare the efficacy and safety of plastic and metal stents. A special focus is placed on studies directly comparing different stent types, including lumen-apposing metal stents (LAMS) and clinical outcomes when draining pseudocysts or WONs. The clinical significance and endoscopic treatment options for DPDS are also discussed. Expert commentary: Endoscopic therapy has become the treatment of choice for different types of pancreatic and peripancreatic collections, the majority of which, however, require no intervention. The use of LAMS has facilitated drainage and necrosectomy in patients with WON or pseudocysts. Serious complications remain a problem in spite of high technical and clinical success rates. DPDS is an increasingly recognized problem in the presence of pseudocysts or WONs but evidence for endoscopic stent placement in this situation remains insufficient.

Endoscopy has emerged as a mainstay in the management of pancreatic fluid collections (PFCs), representing an important advance in clinical medicine that has significantly improved the risk-benefit ratio of treating this complex patient population. While endoscopic pseudocyst drainage has generally supplanted surgical and percutaneous approaches, the optimal strategy for walled-off necrosis remains variable and multi-disciplinary despite an emerging trend from randomized trials favoring endoscopy. Although several issues pertaining to endoscopic drainage appear to have been settled - such as the use of endoscopic ultrasound - other pressing questions - including the optimal prosthesis and debridement strategy - remain unanswered, and rigorous investigation is needed. This review aims to provide an evidence-based but practical appraisal of the endoscopic drainage of PFCs through the perspective of the author, with an emphasis on relevant clinical and endoscopic considerations and important research questions.

Although metal stents are increasingly being used for endoscopic transmural drainage of pancreatic fluid collection (PFC), the advantages of metal stents in comparison with plastic stents are not clear.

The aim of this study is to compare the clinical outcomes and adverse events between patients receiving endoscopic transmural drainage of PFCs through metal or plastic stents.

We performed a systematic literature search to identify all published manuscripts comparing metal and plastic stents for PFC drainage. The primary outcome was clinical success, and the secondary outcomes were technical success, procedure time, overall cost, adverse events, and recurrence.

Seven studies were considered to be appropriate for this meta-analysis. Metal stents showed a higher clinical success rate (odds ratio (OR) 3.39, 95% confidence interval (CI) 2.05-5.60) and a lower overall adverse event rate (OR 0.37, 95% CI 0.21-0.66) than plastic stents. In subgroup analyses, metal stents showed higher clinical success rates than plastic stents both for pseudocyst (OR 5.35, 95% CI 1.35-21.19) and walled-off necrosis (OR 3.37, 95% CI 1.89-5.99).

Metal stents are superior to plastic stents for endoscopic transmural drainage of PFC because they have a higher clinical success rate and lower rate of adverse events.

Pancreatic leaks occur as a complication of upper gastrointestinal surgery, acute pancreatitis, or abdominal trauma. Pancreatic fistulas and leaks are primarily managed conservatively. Overall, conservative measures are successful in more than half of cases. Whenever conservative treatment is not efficient, surgery is usually considered the treatment of choice. Nowadays however, endoscopic treatment is being increasingly considered and employed in many cases, as a surgery sparing intervention.

To introduce a classification of pancreatic fistulas according to the location of the leak and ductal anatomy and finally propose the best suited endoscopic method to treat the leak according to current literature.

We performed an extensive review of the literature on pancreatic fistulae and leaks.

In this paper, we review the various types of leaks and propose a novel endoscopic classification of pancreatic fistulas in order to standardize and improve endoscopic treatment.

A proper and precise diagnosis should be made before embarking on endoscopic treatment for pancreatic leaks in order to obtain prime therapeutic results. A multidisciplinary team of interventional endoscopists, pancreatic surgeons, and interventional radiologists is best suited to care for these patients.

Management of disconnected pancreatic duct syndrome is complex and is increasingly approached using emerging endoscopic techniques. Herein, we present a case of recurrent pancreatitis in an elderly woman complicated by pseudocyst formation and complete pancreatic duct disruption. Her condition was treated with a novel combination of transpapillary stenting and cystduodenostomy in which a pancreatic duct stent was placed into an opening in the pseudocyst wall through a lumen-apposing metal stent. This allowed for effective drainage into the gastrointestinal tract and resolution of duct disruption. Post-procedure, the patient has had recovery of nutritional status and no further recurrence of pancreatic fluid collection. Endoscopic approaches to complete pancreatic duct disruption represent a viable and less invasive alternative to surgical management in selected cases.

Disconnected pancreatic duct syndrome is a circumferential interruption of the pancreatic duct. It usually occurs secondary to pancreatitis and carries significant diagnostic and management challenges. We present a case of disconnected pancreatic duct syndrome that represented a diagnostic and management dilemma for both medical and surgical teams. The aim of this article is to share a successful management experience of disconnected pancreatic duct syndrome with other physicians and to perform a brief but focused literature review on this challenging condition.

Walled-off necrosis (WON) is a new term for encapsulated necrotic tissue after severe acute pancreatitis. Various terminologies such as pseudocyst, necroma, pancreatic abscess, and infected necrosis were previously used in the literature, resulting in confusion. The current and past terminologies must be reconciled to meaningfully interpret past data. Recently, endoscopic necrosectomy was introduced as a treatment option and is now preferred over surgical necrosectomy when the expertise is available. However, high-quality evidence is still lacking, and there is no standard management strategy for WON. The consensus meeting aimed to clarify the diagnostic criteria for WON and the role of endoscopic interventions in its management. In the Consensus Conference, 27 experts from eight Asian countries took an active role and examined key clinical aspects of WON diagnosis and endoscopic management. Statements were crafted based on literature review and expert opinion, employing the modified Delphi method. All statements were substantiated by the level of evidence and the strength of the recommendation. We created 27 consensus statements for WON diagnosis and management, including details of endoscopic procedures. When there was not enough solid evidence to support the statements, this was clearly acknowledged to facilitate future research. Proposed management strategies were formulated and are illustrated using flow charts. These recommendations, which are based on the best current scientific evidence and expert opinion, will be useful for guiding endoscopic management of WON. Part 2 of this statement focused on the endoscopic management of WON.

Drainage is usually recommended in symptomatic walled off pancreatic necrosis (WOPN). WOPN presenting with pain may get symptomatic relief if the pancreas is given rest by initiating nasojejunal (NJ) feed.

The aim of this was to prospectively study the efficacy of nasojejunal (NJ) feeding in patients of WOPN presenting with abdominal pain.

Twenty-one patients (15 M; 35 ± 12 years) with WOPN (size 7-16 cm) presenting with pain underwent NJ tube placement under endoscopic guidance. Following this, pain relief and long-term outcome were studied.

Etiology of pancreatitis was alcohol in 12, gall stones in 6, and idiopathic in 3 patients. NJ tube was successfully placed in all patients and 17/21 (81%) patients had symptomatic relief in 1-4 days (mean 2 ± 1 days) following NJ feeding. NJ tube was removed after 7-10 days (mean 7 ± 1 days), and 14 (61%) patients remained pain free and follow-up imaging (1-8 months) revealed complete resolution or decrease in size of WOPN. Three patients had recurrence of pain and were successfully treated with endoscopic drainage.

NJ feeding improves pain in the majority of patients with WOPN and thus obviates or delays drainage. Majority of nonresponders had disconnected pancreatic duct syndrome (DPDS).

Endoscopic ultrasound (EUS) has emerged as an important diagnostic and therapeutic modality in the field of gastrointestinal endoscopy. EUS provides access to many organs and lesions which are in proximity to the gastrointestinal tract and thus giving an opportunity to target them for therapeutic and diagnostic purposes. This modality also provides a real time opportunity to target the required area while avoiding adjacent vascular and other structures. Therapeutic EUS has found role in management of pancreatic fluid collections, biliary and pancreatic duct drainage in cases of failed endoscopic retrograde cholangiopancreatography, drainage of gallbladder, celiac plexus neurolysis/blockage, drainage of mediastinal and intra-abdominal abscesses and collections and in targeted cancer chemotherapy and radiotherapy. Infact, therapeutic EUS has emerged as the therapy of choice for management of pancreatic pseudocysts and recent innovations like fully covered removable metallic stents have improved results in patients with organised necrosis. Similarly, EUS guided drainage of biliary tract and pancreatic duct helps drainage of these systems in patients with failed cannulation, inaccessible papilla as with duodenal/gastric obstruction or surgically altered anatomy. EUS guided gall bladder drainage is a useful emergent procedure in patients with acute cholecystitis who are not fit for surgery. EUS guided celiac plexus neurolysis and blockage is more effective and less morbid vis-à-vis the percutaneous technique. The field of interventional EUS is rapidly advancing and many more interventions are being continuously added. This review focuses on the current status of evidence vis-à-vis the established indications of therapeutic EUS.