Management of pancreatic fluid collections in patients with acute pancreatitis

Abstract

Abstract Acute pancreatitis is associated with development of pancreatic fluid collections (PFCs). Acute PFCs that develop in interstitial edematous pancreatitis mostly resolve but some may persist and evolve into pseudocysts. Acute necrotic collections occurring in acute necrotizing pancreatitis generally persist and evolve into walled-off necrosis (WON) after 3 to 4 weeks. Most acute fluid collections do not require drainage unless they are large and cause compression of adjacent organs, contribute to increase in intraabdominal pressure or become infected. Acute infected collections can be managed with antibiotics and percutaneous drainage but may require necrosectomy either by minimally invasive surgical or endoscopic methods such as video-assisted retroperitoneal debridement and percutaneous endoscopic necrosectomy. Mature sterile collections, that is, pseudocyst and WON with a defined wall are best treated by internal transmural drainage which can be achieved either by per-oral endoscopic or surgical, preferably laparoscopic, method. Of late, infected PFCs are increasingly being treated with an endoscopic step-up approach that has been shown to be better than minimally invasive surgical step-up approach in terms of lesser complications. Use of lumen apposing metal stents during endoscopic drainage has emerged as an attractive option that facilitates necrosectomy in infected WON.