**2.8 Trans-papillary drainage of PFCs**

*Pancreatitis*

pancreatic fistulas (5 vs 32%, p < 0.01) and the length of hospital stay were lower in the endoscopy group [7]. In another randomized trial including 66 patients with infected WON, ETD was associated with significantly reduced major complications (0.15 vs. 0.69), lowered costs (75,830 \$ vs. 117,492 \$), lower incidence of pancreatic fistula (0 vs. 28.1%), and increased quality of life as compared to minimally invasive surgery [45]. In a recent systematic review including two randomized trials and four observational studies, ETD was associated with lower mortality, risk of major organ failure, adverse events, and length of hospital stay [44]. These trials suggest that endoscopic step-up approach should be preferred over minimally invasive surgical

Endoscopic and surgical cyst-gastrostomy have been compared in several studies

[46–50]. Initial non-randomized trials found surgical drainage to be superior to endoscopic drainage of pseudocysts [50]. However, subsequent randomized studies concluded that endoscopic drainage achieves similar outcomes as compared to surgical drainage [46, 49, 47]. In addition, EUS guided cyst-gastrostomy is less invasive, cost saving, and associated with a shorter length of a post procedure hospital stay when compared with surgical cyst-gastrostomy [46, 47]. In a recent systematic review and meta-analysis including six studies (342 patients), there was no significant difference between surgical and endoscopic treatment success rates, adverse events, and recurrence for pancreatic pseudocysts [51]. To conclude, the current evidence suggests that endoscopic drainage is as efficacious as surgical cyst-

gastrostomy for pseudocysts with shorter hospital stay and reduced costs.

Percutaneous catheter drainage remains an important modality even in the era of minimally invasive endoscopic or surgical treatments. In different studies, percutaneous drainage alone was successful in 35–50% of cases with WON [52]. Percutaneous drainage can be used as an adjunctive to endoscopic drainage in selected cases with large PFCs extending into paracolic gutters or pelvis. In addition, percutaneous drainage is useful in acute or ill-defined PFCs (<4 weeks) where endoscopic drainage may not be feasible. Percutaneous tract can also be utilized for endoscopic and VARD [43]. Having described all the major advantages of percutaneous catheter drainage, the major limitation remains the development of external

As compared to percutaneous approach, endoscopic drainage is associated with

Dual modality drainage (DMD) involves the simultaneous or sequential use of endoscopic and percutaneous approaches for symptomatic PFCs. Several studies have concluded the utility of DMD in symptomatic PFCs especially WON [54, 55]. The proposed advantages of this technique include a quicker recovery and reduced chances of forming an external pancreato-cutaneous fistula. In the study by Gluck et al., the use of DMD was associated with reduced length of hospital stay, and less

significantly better clinical success, a lower re-intervention rate, and a shorter hospital length of stay [53]. Therefore, percutaneous drainage is only performed in cases where either endoscopic drainage is not available or not feasible (ill-defined or

step-up approach for the management of PFCs.

**2.6 Endoscopic vs. percutaneous drainage**

distantly located collections).

**2.7 Dual modality drainage**

pancreatocutaneous fistula which may be difficult to treat.

requirement of radiological or endoscopic interventions [55].

**2.5 Endoscopic vs. surgical drainage: pseudocysts**

**14**

Trans-papillary drainage (TPD) of PFCs may be useful in certain scenarios as follows: (a) small size of cyst (<5 cm) communicating with main pancreatic duct (PD), (b) as an adjunct to ETD in cases with PD leak or disconnected PD, (c) chronic pancreatitis with an obstructed PD communicating with a pseudocyst, and (d) management of external pancreatic fistula after percutaneous or surgical drainage [22]. When used as a primary modality, TPD provides the path of least resistance for the pancreatic juice, thereby diverting it away from the cyst. There is a potential of cyst infection with TPD and therefore, antibiotics should be routinely given to these patients. TPD may be useful in preventing recurrences of PFCs following ETD in cases with PD leak and disconnected PD [57]. We do not routinely perform TPD as an adjunct to ETD in all the cases. In our practice, we evaluate the PD anatomy using an magnetic resonance cholangiopancreatogram (MRCP) prior to removal of stents placed during ETD. In cases with a PD stricture, leak or disconnection we attempt placing a trans-papillary PD stent. Subsequently, trans-papillary stents are removed or exchanged (as per the PD morphology) after 4–6 weeks. However, trans-papillary stenting may not be always feasible especially in cases with a disconnected PD. In these cases, transmural plastic stents can be left in situ and metal stents can be exchanged with plastic stents [58]. However, the latter approach needs to be substantiated by high quality randomized studies. Nevertheless, metal stents should be removed between 2 and 4 weeks irrespective of the PD anatomy due to the risk of buried stent syndrome and delayed bleeding.
