**4. Individualized approach to pancreatic fluid collections**

The management of PFCs requires an individualized approach based on their maturity (acute or well defined), contents, and anatomical location in relation to gastroduodenal wall (**Figure 7**). Asymptomatic PFCs do not require drainage irrespective of their size. Similarly, symptomatic and ill-defined APFCs are managed conservatively with antibiotics (if necessary), nutritional support, and analgesics initially. In non-responders, percutaneous drainage is a reasonable next step in acute collections.

Mature PFCs with a well-defined wall and in close proximity to gastroduodenal wall can be managed endoscopically using plastic or metal endoprostheses in majority of the cases. We prefer LCMS in PFCs containing substantial necrotic debris identified on EUS or MRI. Occasionally, the PFC is situated away (>1–1.5 cm) from the gastroduodenal wall and not amenable to endoscopic drainage. In these cases, percutaneous or minimally invasive surgical drainage (e.g., VARD) are alternatives.

Subsequent interventions are carried in a step-up fashion based on the persistence of significant symptoms. Endoscopic or percutaneous necrosectomy is performed in non-responders who underwent ETD or percutaneous drainage, respectively, as the primary mode of drainage. We prefer intermediary steps including naso-cystic lavage and de-clogging of LCMS before proceeding to DEN. In our experience, only a minor fraction of cases require DEN with this approach [14]. Some cases do not respond to the aforementioned minimally invasive step-up approach and require an open surgical debridement.

#### **Figure 7.**

*Approach to symptomatic pancreatic fluid collections. VARD, video-assisted retroperitoneal debridement; LCMS, large caliber metal stent; \*\*percutaneous drainage can be performed either simultaneously with endoscopic transmural drainage or sequentially in non-responders.*

## **5. Conclusions**

The management of PFCs requires a multidisciplinary approach involving experienced endoscopists, interventional radiologists, pancreatic surgeons, and nutritionists. Endoscopic drainage is the preferred first line approach to symptomatic and infected PFCs. Percutaneous drainage is useful in selected scenarios and can complement the benefits of endotherapy in large collections extending toward

**17**

**Author details**

Zaheer Nabi\* and D. Nageshwar Reddy

provided the original work is properly cited.

Asian Institute of Gastroenterology, Hyderabad, India

\*Address all correspondence to: zaheernabi1978@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Endoscopic Management of Pancreatic Fluid Collections: An Update*

pelvis. The approach to PFCs should not be rigid and should be individualized for each patient. In general, a step-up approach minimizes the morbidity associated with open surgical drainage and is usually successful in majority of the patients. However, some cases do require open surgical debridement despite of all the recent

*DOI: http://dx.doi.org/10.5772/intechopen.89764*

advancements in endotherapy.

*Endoscopic Management of Pancreatic Fluid Collections: An Update DOI: http://dx.doi.org/10.5772/intechopen.89764*

*Pancreatitis*

acute collections.

**4. Individualized approach to pancreatic fluid collections**

approach and require an open surgical debridement.

*endoscopic transmural drainage or sequentially in non-responders.*

The management of PFCs requires an individualized approach based on their maturity (acute or well defined), contents, and anatomical location in relation to gastroduodenal wall (**Figure 7**). Asymptomatic PFCs do not require drainage irrespective of their size. Similarly, symptomatic and ill-defined APFCs are managed conservatively with antibiotics (if necessary), nutritional support, and analgesics initially. In non-responders, percutaneous drainage is a reasonable next step in

Mature PFCs with a well-defined wall and in close proximity to gastroduodenal wall can be managed endoscopically using plastic or metal endoprostheses in majority of the cases. We prefer LCMS in PFCs containing substantial necrotic debris identified on EUS or MRI. Occasionally, the PFC is situated away (>1–1.5 cm) from the gastroduodenal wall and not amenable to endoscopic drainage. In these cases, percutaneous or minimally invasive surgical drainage (e.g., VARD) are alternatives. Subsequent interventions are carried in a step-up fashion based on the persistence of significant symptoms. Endoscopic or percutaneous necrosectomy is performed in non-responders who underwent ETD or percutaneous drainage, respectively, as the primary mode of drainage. We prefer intermediary steps including naso-cystic lavage and de-clogging of LCMS before proceeding to DEN. In our experience, only a minor fraction of cases require DEN with this approach [14]. Some cases do not respond to the aforementioned minimally invasive step-up

The management of PFCs requires a multidisciplinary approach involving experienced endoscopists, interventional radiologists, pancreatic surgeons, and nutritionists. Endoscopic drainage is the preferred first line approach to symptomatic and infected PFCs. Percutaneous drainage is useful in selected scenarios and can complement the benefits of endotherapy in large collections extending toward

*Approach to symptomatic pancreatic fluid collections. VARD, video-assisted retroperitoneal debridement; LCMS, large caliber metal stent; \*\*percutaneous drainage can be performed either simultaneously with* 

**16**

**5. Conclusions**

**Figure 7.**

pelvis. The approach to PFCs should not be rigid and should be individualized for each patient. In general, a step-up approach minimizes the morbidity associated with open surgical drainage and is usually successful in majority of the patients. However, some cases do require open surgical debridement despite of all the recent advancements in endotherapy.
