Management of pancreatic fluid collections: A comprehensive review of the literature

Abstract

Pancreatic fluid collections (PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis (WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is 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 WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct (PD) exploration should be performed concurrent to PFC drainage. 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. Any pancreatic ductal disruption should be bridged with endoscopic stenting.

Keywords: Pancreatic fluid collection; Pancreatic fluid collection; Pseudocyst; Walled-off pancreatic necrosis; Walled-off pancreatic necrosis; Pancreatitis

Core tip: Pancreatic fluid collections are a frequent complication of pancreatitis. Management includes correctly classifying these collections, initiating early enteral feeding, and draining symptomatic collections. Endoscopic ultrasound with stent placement is the technique of choice. Both metal and plastic stents are efficacious, though metal stents may offer an advantage. When necrosis is present within the collection, direct endoscopic necrosectomy may be required in addition to drainage. Lumen apposing metal stents allow for direct endoscopic necrosectomy through the stent and are preferred in these patients. When a pancreatic duct leak is suspected, endoscopic investigation and stenting is mandated.