Management of pancreatic fluid collections: A concise review

A pancreatic fluid collection (PFC) is a local complication of acute pancreatitis. Most PFCs spontaneously resolve and only a minor group of patients need therapeutic intervention. When conservative treatment fails, patients with symptomatic or infected PFCs undergo drainage, either with or without necrosectomy. Three drainage techniques, i.e., endoscopic, percutaneous, and minimally invasive surgery (MIS), are complementary to achieve the symptomatic resolution of the PFC. Endoscopic drainage (ED) with a high technical and clinical success rate has become the current standard of care for mature PFCs. Among the ED techniques, endoscopic ultrasound-guided transmural drainage (EUS-TD) is preferred over conventional transmural drainage for pancreatic pseudocysts or walled-off necrosis (WON). For PFC that is not encapsulated and <4 weeks old, percutaneous catheter drainage ± sinus tract endoscopy works well and is lifesaving in people with abdominal compartment syndrome. Pancreatic necrosectomy is an adjunctive procedure in patients who fail to improve after initial transmural or percutaneous drainage. MIS plays a role if the PFC shows inadequate response to combined drainage and debridement procedures, with open necrosectomy the last resort. Infected pancreatic necrosis is the most dreaded complication of acute necrotizing pancreatitis with a significantly high mortality rate (20%–30%). The “step-up” approach is recommended for infected as well as symptomatic WON. The “surgical step-up” and the “endoscopic step-up” are preferred for infected acute necrotic collection and infected WON, respectively. Various adjunctive methods such as stopping proton-pump inhibitors, hydrogen peroxide irrigation, and nasocystic catheter irrigation help in the earlier resolution of WON by reducing the number of sessions of direct endoscopic necrosectomy (DEN). Using lumen-apposing metal stents for EUS-guided drainage of PFCs has revolutionized the technique with more effective drainage and provides a conduit for DEN.