Endoscopic Therapy of Necrotizing Pancreatitis and Pseudocysts

Endoscopic therapy has become an essential component in the management of postpancreatitis complications, such as infected and/or symptomatic pancreatic pseudocysts and walled-off necrosis. However, although there have been 2 recent randomized, controlled trials performed, a general lack of comparative effectiveness data regarding the timing, indications, and outcomes of these procedures has been a barrier to the development of practice standards for therapeutic endoscopists managing these issues. This article reviews the available data and expert consensus regarding indications for endoscopic intervention, timing of procedures, endoscopic technique, periprocedural considerations, and complications.

Key points

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In the last several years, endoscopic management of pancreatic pseudocysts and walled-off necrosis has come to serve as an important primary interventional technique for therapeutic gastroenterologists.
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Although a primary means of treatment at many centers, it additionally serves as an adjunct to other minimally invasive interventional techniques, such as percutaneous drainage or laparoscopic necrosectomy and video-assisted retroperitoneal debridement.
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Endoscopic drainage and debridement are most clearly indicated in patients with well-encapsulated pancreatic or peripancreatic collections of fluid or necrotic debris with signs of infection and clinical deterioration, luminal or biliary obstruction, or severe pain.
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To ensure optimal patient outcomes, the use of periprocedural antibiotics, endoscopic ultrasonography guidance for localization of puncture site, multiple pigtail drains or enteral stents at the fistula site, serial direct endoscopic necrosectomy as needed, and serial imaging is recommended.
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The endoscopist should be prepared to repeat procedures as needed depending on the patient’s clinical status and imaging results.
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Although more prospective comparative trials are needed to refine future practice guidelines, endoscopic management of pancreatic pseudocysts and walled-off necrosis is a safe and effective therapeutic option in the appropriate patient population.