EUS-Guided Drainage of Pancreatic Collections and Necrosectomy
Ryan Law, DO
Todd H. Baron, MD
Injury to the pancreas regardless of the etiology results in parenchymal inflammation, often leading to disruption of the main pancreatic duct and/or secondary branches. Following ductal injury, leakage of pancreatic contents may lead to formation of fluid-filled pancreatic or peripancreatic collections with or without the presence of solid debris. Clinically severe acute pancreatitis evolves over several weeks culminating in walled-off necrosis (WON) in many cases (Fig. 32.1). The aim of endoscopic therapy is to provide drainage of liquid contents and mechanical removal of necrotic tissue, if necessary. Endoscopic intervention remains the current standard of care for patients with pancreatic fluid collections. This chapter will focus on the indications, techniques, and outcomes of endoscopic therapy and management of pancreatic fluid collections.
1. CT or MRI should be performed before endoscopic intervention to assess the size, shape, wall thickness, and contents, discern adjacent relevant vascularity, and ascertain the relationship between the cavity and gastrointestinal lumen, presence of gas, and solid material.
2. CT and MRI appearance of PFCs can vary widely. CT showing nondependent air within a cavity is indicative of the presence of solid debris.
3. Understanding the burden of necrosis, the presence or absence of extension into the paracolic gutters and interactions between multiple cavities, if present, will guide the index procedure and streamline subsequent interventions.
INDICATIONS FOR AND TIMING OF ENDOSCOPIC DRAINAGE
1. Gastric outlet obstruction due to compression
2. Biliary obstruction due to compression
FIG. 32.1 Coronal image of abdominal CT findings of walled-off pancreatic necrosis abutting the stomach. Note heterogeneity within the collection.
3. Abdominal pain
4. Failure to thrive (fatigue, anorexia, weight loss)
1. Uncontrolled coagulopathy
2. Overt luminal perforation
1. Ensure adequate international normalized ratio (INR) and platelet count
2. Administration of broad-spectrum antibiotics
3. Anesthesia support
4. Carbon dioxide for insufflation