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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., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Since the original description of pancreatic fluid collections (PFC) in 1761 by Morgagni, their diagnosis, description, and management have continued to evolve. The mainstay of therapy for symptomatic PFCs has been the creation of a communication between a PFC and the stomach, to enable drainage. Surgical creation of these drainage conduits had been the gold standard of therapy; however, there has been a paradigm shift in recent years with an increasing role of endoscopic drainage. The techniques of endoscopic drainage have evolved from blind fluid aspiration to include endoscopic necrosectomy and the placement of lumen-apposing metal stents., (Copyright © 2018 Elsevier Inc. All rights reserved.)

An analysis of treatment results was made in 26 patients with postnecrotic cysts of different degree of maturity. The laparotomy with trans-gastral cystogastrostomy on the external drainage were performed on 11 patients. A new modified operation underwent 15 patients. This operation was transgastric cystogastrostomy on the external drainage from mini-access, which was developed in 2011. The laparotomy of 4–5 cm was made in pseudocyst projection of the pancreas using a standard set of tools «mini-assistant». Postoperative period have passed without complications in all the patients. The drainage was removed on 30–40 days of postoperative period. The terms of hospital stay reduced from (14,4±0,9) bed/ days to (10,8±0,5) bed/days due to application of proposed method of treatment.

Introduction: In recent years, the practice of abdominal surgery marked increase in the number of patients with pancreatic cysts. Tactics of treatment of this disease is still disputable., Material and Methods: The article analyzes the treatment of 128 patients with formed pancreatic cysts. They were divided into three groups: 1) external drainage - 44 (34.4%); 2) internal drainage - 41 (32.0%); 3) resection surgery - 43 (33.6%)., Results: The duodenum resections were introduced for the treatment of the pancreatic head cysts - 21 (48.8%). Resection methods in the number of postoperative complications (23.3%) could be compared with the operations of the internal drainage of pancreatic cysts (19.5%), although the resection methods are technically more difficult and traumatic. 66 (51.6%) patients were observed in the long-term period. The number of postoperated disease recurrences was more in group 1 (28.6%). Quality of life indicators (SF-36) were higher in group 3. We marked the best results after resection operations., Conclusion: So this type of operation can be recommended for the treatment of patients with formed pancreatic cysts as the most radical method.

Background: After pancreatic head resection the reconstruction of small and fragile bile ducts is technically demanding, resulting in more postoperative bile leaks. One option for the reconstruction is the placement of a T-tube drainage at the site of the anastomosis., Material and Methods: Standard reconstruction after pancreatic head resection was an end-to-side hepaticojejunostomy with PDS 5.0, 15-25 cm distally from the pancreaticojejunostomy. For patients with a small bile duct diameter (≤ 5 mm) or a fragile bile duct wall the reconstruction was performed with PDS 6.0 and a T-tube drainage at the side of the anastomosis., Results: The reconstruction with a T-tube drainage at the site of the anastomosis is technically easy to perform and offers the opportunity for immediate visualisation of the anastomosis in the postoperative period by application of water soluble contrast medium. If a bile leak occurs, biliary deviation through the T-tube drainage can enable a conservative management without revisional laparotomy in selected patients. Whether or not a conservative management of postoperative bile leaks will lead to more bile duct strictures is a subject for further investigations., Conclusion: A T-tube drainage at the site of the anastomosis can probably not prevent postoperative bile leaks from a difficult hepaticojejunostomy, but in selected patients it offers the opportunity for a conservative management resulting in less re-operations. Therefore we recommend the augmentation of a difficult hepaticojejunostomy with a T-tube drainage., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Endoscopic therapy of walled-off pancreatic necrosis (WOPN) via direct intracavitary debridement is described., Objective: To compare direct endoscopic necrosectomy with conventional transmural endoscopic drainage for the treatment of WOPN., Design: Retrospective, comparative study., Setting: Academic tertiary-care center., Patients: Patients referred to Mayo Clinic, Rochester, Minnesota, since April 1998 for endoscopic drainage of WOPN., Interventions: Each patient underwent standard endoscopic drainage that consisted of transmural cavity puncture, dilation of the fistula tract, and placement of a large-bore stent(s). Patients were classified into the direct endoscopic necrosectomy group if, during any of their procedures, adjunctive direct endoscopic necrosectomy was performed; all others were in the standard drainage group., Main Outcome Measurements: Success was defined as resolution of the necrotic cavity without the need for operative or percutaneous intervention., Results: Forty-five patients were identified who met study criteria: 25 underwent direct endoscopic necrosectomy, and 20 underwent standard endoscopic drainage. There were no differences in baseline patient or cavity characteristics. Successful resolution was accomplished in 88% who underwent direct endoscopic necrosectomy versus 45% who received standard drainage (P < .01), without a change in the total number of procedures. The maximum size of tract dilation was larger in the direct endoscopic necrosectomy group (17 mm vs 14 mm, P < .02). Complications were limited to mild periprocedural bleeding with equivalent rates between groups., Limitations: Retrospective, referral bias, single center., Conclusions: Direct endoscopic necrosectomy achieves higher rates of resolution, without a concomitant change in the number of endoscopic procedures, complication rate, or time to resolution compared with standard endoscopic drainage for WOPN. The need for fewer postprocedural inpatient hospital days and a decrease in the rate of cavity recurrence are also likely benefits of this technique.

Endosonography (EUS) has become the accepted procedure for drainage of pancreatic fluid collections in the past decade. EUS was shown to be safe and effective and it has been the first-line therapy for uncomplicated pseudocysts. Where walled-off pancreatic necrosis was originally thought to be a contraindication for endoscopic treatment, multiple case series have now shown that these fluid collections also can be treated endoscopically with low morbidity and mortality. Analogous to the treatment of pancreatic fluid collections, others, such as abscesses in the lower and upper abdomen, have also been treated successfully, although there is limited literature in this regard, EUS appears to be a useful technique in natural orifice transluminal endoscopic surgery (NOTES) procedures as well.

Introduction: Treatment of pancreatic postoperative collections are usually managed with a multidisciplinary team. Different managements are possible: abstention, external drainage, endoscopic treatment or surgery., Methods: We report on a case series of five patients with a postoperative pancreatic collection, endoscopically managed. Patients underwent all a CT scan associated or not with endoscopic ultrasonography., Results: An endoscopic cystenterosotomy was performed in all the cases, with two double pig tail stents sometimes associated with nasocystic drainage for clearing the cyst lumen and with transpapillary drainage in one case. All the procedures were successful and patients healed in all the cases with the disappearance of the radiological image within a 33 days to three months range with one complication due to superinfection of the drained cyst, endoscopically managed with a nasocystic catheter., Conclusion: Therapeutic endoscopy, with a multidisciplinary approach, is a promising way to manage postoperative pancreatic collections.

Background: Much attention has been focused on the competence to perform endoscopic procedures. The aim of this study was to determine the impact of procedure experience on patient outcomes after endoscopic pancreatic fluid collection drainage., Methods: Outcomes for consecutive patients with symptoms from pancreatic fluid collections who were referred for endoscopic transmural and/or transpapillary drainage were analyzed retrospectively. Collections were classified as acute pseudocyst, chronic pseudocyst, and pancreatic necrosis. To assess the impact of endoscopist experience, outcomes for patients who underwent the first 20 procedures were compared with those for patients who had subsequent procedures., Results: In total, 175 patients underwent pancreatic fluid collection drainage; 40 (23%) acute pseudocyst, 78 (44%) chronic pseudocyst, and 57 (33%) pancreatic necrosis. Procedure complication rates, collection recurrence rates, and patient outcomes after acute pseudocyst drainage were independent of endoscopist experience. There was a dramatic improvement in chronic pseudocyst resolution rates after the first 20 procedures versus subsequent procedures (45% vs. 93%; p = 0.0002) and a reduction in days to resolution (50 days, initial 20 procedures vs. 33.5 days, subsequent procedures; p = 0.05). In patients with pancreatic necrosis, there was a decrease in median hospital stay with greater experience (23 days to 15 days; p = 0.04)., Conclusions: Resolution of chronic pseudocyst after endoscopic drainage improves markedly with increasing endoscopist experience. Future prospective studies assessing skill acquisition are required to define the minimum number of collection drainage procedures at which competence can be achieved.

Results of endoscopic drainage of postnecrotic pancreatic cysts in 12 patients were analyzed. Possibilities of the method are limited by location of the cysts in pancreatic head and corpus. Clear visualization of the cysts on the gastric or duodenal wall is the main condition for this procedures feasibility. Surgery must be started with point burning in the wall that is safe and permits the surgeon to stop procedure when cyst is not found. When the cyst is drained through the duodenal lumen, it is necessary to visualize Veter's papilla and perform the procedure below it to prevent lesion of a distal part of the common bile duct. Section of the cyst with wall thickness to 3-4 mm from the duodenal lumen and the ikness to 6-7 mm from the stomach is safe enough. Endoscopic procedures are not indicated in hypertension in the bile ducts.

Neoplastic cysts of the pancreas have been recognized since the nineteenth century, and although differences between neoplastic and proliferative cysts were acknowledged, they were treated similarly, first by marsupialization and later by internal drainage. Increased awareness of the malignant potential of neoplastic cysts, as well as advances in surgical techniques, made excision the preferred treatment for these lesions as early as the 1940s, but errors in diagnosis were frequent, and even to this date, continue to account for cases of pancreatic cystic tumors treated by drainage.

Background: A prerequisite for endoscopic drainage of pancreatic fluid collections without EUS is the presence of a visible bulge in the GI wall. Our experience with endoscopic cystostomy of nonbulging pancreatic fluid collections is described., Methods: Thirty-three patients underwent 34 endoscopic attempts at transmural drainage of nonbulging pancreatic fluid collections over a 2-year period. The etiology of the nonbulging pancreatic fluid collections was chronic pancreatitis in 26 cases and acute pancreatitis in 7. Indications for drainage included one or more of the following: abdominal pain, infection, biliary obstruction, and external fistula. The diameter of the collections ranged from 20 to 160 mm (median 52 mm)., Results: Thirty-two of 34 drainage attempts were successful (94%). Eighteen cystostomies were performed under fluoroscopy alone and 14 by EUS together with fluoroscopy. Procedure-related complications occurred with 3 of 34 attempts (8%). Surgery was not required for treatment of the complications and there were no deaths from the procedure. Follow-up was available for 31 patients (median 21 months, range 9 to 40 months). One nonbulging pancreatic fluid collections recurred 7 months after drainage., Conclusions: Endoscopic cystenterostomy of nonbulging pancreatic collections is feasible, and the results of the procedure are similar to those of cystenterostomy for bulging collections.

An insulin-requiring type 2 diabetic patient became insulin-resistant with development of a pancreatic pseudocyst following cholecystitis and cholecystectomy. Drainage of the cyst fluid was followed by rapid return to his prior insulin requirement. As there were no indications of insulin allergy, obesity, or hormonal imbalance, we postulate a subclinical state of pancreatitis that was relieved with drainage of the pseudocyst fluid.

Among previous cases of mediastinal pseudocyst requiring surgical decompression, all but one had been found at surgery to occupy a position both in the mediastinum and in the upper abdomen. In the present case, although preoperative ultrasound and CT scans suggested that the pseudocyst was straddling the diaphragm, an abdominal portion could not be found at surgery, and the pseudocyst was drained successfully through the diaphragm by a Roux-en-Y loop of jejunum. Because ultrasound and CT scan may not be able to determine the precise relationship of a mediastinal pseudocyst to the diaphragm and the availability of the lower portion of the pseudocyst for surgical decompression, an endoscopic retrograde cholangiopancreatography is strongly recommended as part of the preoperative evaluation.

We describe a new method for the percutaneous drainage of pancreatic pseudocysts using a transgastric approach. We used this technique in three dogs and six patients for whom no other "safe" access route was available. The procedures were performed under US guidance alone or with US combined with fluoroscopy. No complications were observed.

Between 1967 and 1980 a total of 153 benign pancreatic pseudocysts were operatively treated in 148 patients. Most frequently drainage of the cyst into the small intestine with a Roux-en-y loop was effected. The operative mortality with this method was 5.8%. The total operative mortality was 6.8%. The recurrence rate in all surviving patients was 32.6% during a mean observation period of 56.4 months. There was a correlation between the incidence of recurrence and the etiology of the cyst (chronic, acute and traumatic pancreatitis). Patients in whom the pseudocyst arose from chronic pancreatitis had a recurrence rate of 41.4% as compared to 17.8% in patients with cysts developing after acute pancreatitis. This difference is even more pronounced in the group of the 120 patients in whom a cystojejunostomy was performed. The total recurrence rate of 31.9% is mainly caused by patients with chronic pancreatitis who suffered a relapse in 43.8%. The cysts developing after acute pancreatitis on the other hand had a recurrence rate of only 8.6%. It is concluded that internal drainage of the pancreatic pseudocyst by cystojejunostomy with a Roux-en-y loop is justified in post-traumatic cysts and in those arising after acute pancreatitis. Pseudocysts associated with chronic pancreatitis on the other hand should be resected whenever possible.

Percutaneous punctures and drainage of pancreatic cysts under USE control were conducted in 12 patients. It was found that the method is relatively simple, less injurious, and makes it possible in infected cysts to perform rapid cleansing and drainage of the purulent cavity without the hazard of the development of complications and to achieve in some cases complete sclerosis of the cystic cavity if it is not connected with the ductal system.

Transgastric pancreatic pseudocyst drainage provides unique advantages that mimic the benefits of surgical cystogastrostomy while avoiding the disadvantages of external drainage. This procedure was performed under CT guidance in eight patients with pancreatic pseudocysts. There was no communication with the pancreatic duct at the time of initial aspiration. Communication was later demonstrated in six of eight patients and persisted for the entire duration of drainage. Resolution of the cysts occurred in seven of the eight patients. In one patient an infection of the pancreatic collection developed that required surgery. As with abdominal abscess drainage, a preexisting fistula may be opacified only after several days of catheter drainage and cannot be predicted at the time of initial aspiration. The percutaneous transgastric approach mimics the surgical approach and allows a mature tract to form from the cyst to the stomach. This eliminates the risk of a pancreaticocutaneous fistula and permits tube removal within a reasonable period of time.

The management of immature pancreatic pseudocysts is controversial because surgical external drainage is associated with a high morbidity and mortality rate. A study was conducted during which immature pseudocysts that were enlarging, causing pain or giving respiratory distress were selected for percutaneous drainage and placement of a pigtail drainage catheter under ultrasonographic guidance. This preliminary study of 4 cases demonstrated that this procedure is safe and does not cause morbidity or mortality. It is suggested that there will be no recurrence provided the catheter is well secured and that no communication between the cyst and the pancreatic duct can be seen on sinography and endoscopic retrograde cholangiopancreatography.

Recent advances in the field of imaging diagnosis, particularly sonography and CAT, have permitted the development of the so-called interventional radiology techniques, which have made it possible to resolve a series of complex problems like intraperitoneal abscess and pancreatic pseudocyst. We present the results of treatment of a series of 9 patients diagnosed as pancreatic pseudocyst using percutaneous drainage directed by sonography or CAT. Seven of the pseudocysts were secondary to episodes of acute pancreatitis and two derived from chronic pancreatitis. In 8 of the patients a complete resolution of the process was achieved, in one case after a second drainage attempt when the pseudocyst recurred one year later. The success rate was 88.8% and morbidity and mortality were null.

Traditional concepts of managing pancreatic pseudocysts have changed with the advent of computerized tomography (CT) and ultrasound scanning, but new misconceptions related to spontaneous resolution have replaced some old ones. This report shows a difference in natural history and treatment requirements when pseudocysts are associated with acute versus chronic pancreatitis. There were 42 consecutive patients with pseudocysts treated over 5 years. Thirty-one were known alcoholics, two had gallstone pancreatitis, and nine had idiopathic pancreatitis. An attack of acute pancreatitis was identifiable within 2 months preceding in 22 patients, but there were only chronic symptoms in 20. Spontaneous resolution of the pseudocyst occurred in three patients (7%), all of whom had recent acute idiopathic pancreatitis, normal serum amylase levels, and pancreatograms showing normal pancreatic ducts freely communicating with the pseudocyst. Factors associated with failure to resolve included known chronic pancreatitis, pancreatic duct changes of chronic pancreatitis, persistence greater than 6 weeks, and thick walls (when seen) on scan. Nearly all (18/19) patients with known chronic pancreatitis had successful internal drainage of the pseudocysts immediately upon admission, whereas 6/20 patients with antecedent acute pancreatitis were found to require external drainage at the time surgery was eventually elected. Isoamylase analysis, performed on serum from 19 patients by means of polyacrylamide gel electrophoresis, detected the abnormal pancreatic isoamylase pattern described as "old amylase" in 15. When old amylase was present in the serum, internal drainage was always possible (14/14). In four of five patients whose serum contained no detectable old amylase, internal drainage was not possible regardless of the length of prior observation. There were four nonfatal complications arising from an acute pseudocyst during the wait for maturity. It is concluded that prolonged waiting is expensive and unnecessary for pseudocysts in chronic pancreatitis when there has been no recent acute attack. However, pseudocysts developing after identifiable acute pancreatitis should be observed in the safety of a hospital for up to 6 weeks to allow for either spontaneous resolution or maturation of the cyst wall. The appearance of old amylase in the serum suggests that the pseudocyst wall has achieved sufficient maturity to allow safe internal anastomosis.

The majority of pancreatic pseudocysts develop in a retrogastric situation and are amenable to transgastric cystogastrostomy through the anterior gastric wall. We have encountered two pseudocysts in an unusual situation, in which adherence of the anterior gastric wall to the anterior parietal peritoneum precluded this approach. A retrogastric exposure through the lesser sac allowed for the creation of a cystogastrostomy through the superior aspects of the anterior and posterior gastric walls, adjacent to the lesser curvature of the stomach. This type of drainage is successful despite the theoretical failure to satisfy the dictum of dependent drainage.

60 pancreatic pseudocysts are reported. 29 cystojejunostomies, 22 cystogastrostomies, 2 cystoduodenostomies and 7 external drainages were performed. Most favourable results could be recorded by cystojejunostomy. The total operative mortality was 8.3%, after cystojejunostomie 3.4%. Most dangerous complications were haemorrhage and peritonitis. In the follow up of internal operative drainage approximately 80% excellent or satisfactory results could be observed. Pancreatic pseudocysts lasting more than 6 weeks should be submit to surgical treatment. Cystojejunostomy is the most favourable procedure. External drainage is indicated in emergency or development of complications.

The results of combination of the internal and external drainage of pancreatic cysts in 9 patients are presented. Four variants of the external drainage of cysts after cysto-gastrocystojejunostomy are described. A prolonged washing of the cyst in early postoperative period results in the rapid diminishing of the cyst and in prevention of complications and recurrence of the disease.

In the past, children with pancreatic pseudocysts have been managed surgically. We report seven children 3-13 years old with posttraumatic pancreatic pseudocysts who were managed with percutaneous catheter drainage. All procedures were performed with local anesthesia and intramuscular sedation under sonographic or CT guidance. Two of the pseudocysts were drained via a transgastric approach, the other five via direct transcutaneous access to the pseudocyst. The catheters were in place an average of 25 days (range, 8-66). There were no serious complications. Six patients became asymptomatic with return of the serum amylase to normal and resolution of the pseudocyst on follow-up sonograms. One patient, in whom the catheter became dislodged after 2 weeks, became asymptomatic, but he had a residual 2-cm pancreatic pseudocyst that resolved over the next 6 weeks. Our experience suggests that percutaneous drainage is a safe and effective method of treatment for traumatic pancreatic pseudocysts in children.

In operative treatment of pancreatic pseudocysts by inner drainage there is a risk of massive gastrointestinal bleeding particularly following an anastomosis to the stomach. In 10 patients in whom cystogastrostomy or cystoduodenostomy had been performed elsewhere a second laparotomy was necessary because of acute bleeding. In one patient a cystadenoma of the pancreas had been anastomosed to the duodenum by mistake at the previous operation. The leak of obliteration of the cyst is suggested to be the most important factor in the pathophysiology of bleeding. Inner pseudocyst drainage in a disconnected small bowel loop therefore principally should be performed at the lowest point of the cyst. The indication for an inner cyst drainage, however, must be closely examined since simultaneous pathologic changes in the pancreas often justify a resection to remove the origin of the cyst and, further, averting the complications of an inadequate inner pancreatic cyst drainage.

If pancreatic ductal hypertension explained the pain of chronic pancreatitis, adequate decompression of ectatic ducts should provide lasting relief. We have analysed a personal series of 20 patients (14 men and 6 women) with chronic pancreatitis undergoing one or more drainage procedures. Alcohol was the main aetiological factor, and symptoms had been present for a median of 2.5 years. Pancreatic ductal decompression was achieved by pancreatic sphincteroplasty (n = 4) or longitudinal pancreaticojejunostomy (11). Thirteen patients underwent incidental or additional procedures to decompress the biliary tree: sphincteroplasty (5), choledochal bypass (7) and T-tube drainage (1). Cysts were either drained (7) or resected (3). Two patients required re-operation for subphrenic abscess. Some pancreatic insufficiency was detected preoperatively in 11 patients (exocrine 10, endocrine 4) and was essentially unchanged in all but one patient who came to total pancreatectomy. Two other patients required a coeliac plexus block, but the remaining 17 patients had good pain relief at a median follow-up of 30 months. Ductal drainage procedures effectively relieve the pain of chronic pancreatitis without further compromising pancreatic function.

We report four patients with a protracted history of acute pancreatitis complicated by infected pseudocysts or abscesses. Ultrasonography showed that each patient had cholelithiasis. Endoscopic biliary sphincterotomy was performed resulting in the release of stones, gravel, or pus in all four cases. Three of the patients had successful percutaneous abscess drainage, and one patient was drained surgically. The abscesses all resolved, but one patient died suddenly of acute pulmonary embolism. The other three patients are well. We recommend this combined approach to pancreatic abscess drainage because, if there is obstruction to the flow of pancreatic juice at the ampulla of Vater, it is likely that the pancreatitis and abscess will fail to resolve.

Radiographically guided therapeutic percutaneous catheter drainage was used to manage 25 patients with 27 pancreatic and peripancreatic fluid collections. Nine of 11 (82%) noninfected and 11 of 16 (69%) infected collections were successfully managed with percutaneous drainage. Overall, eight complications and four deaths occurred in this group of patients. The morbidity and mortality in this series is somewhat higher than that previously reported in the radiologic literature. A discussion of the guidelines for percutaneous drainage is presented.