Management of pancreatic collections: an update

Two-step approach for recurrent pancreatic pseudocysts: endoscopic ring drainage of the stent transpapillary combined with the posterior gastric wall

Pancreatic pseudocyst is a complication of pancreatitis, with an incidence of about 5-16% and a incidence of about 20-40% in chronic pancreatitis. There are various ways to treat pancreatic pseudocysts, but the recurrence rate of cysts is as high as 23.9%. There are not many clinical options for the treatment of recurrent pseudocysts, and there is still a high recurrence of pseudocysts after EUS guided drainage alone. We present here a promising endoscopic treatment for patients with recurrent pancreatic pseudocyst.

Pancreatic pseudocyst: The past, the present, and the future

A pancreatic pseudocyst is defined as an encapsulated fluid collection with a well-defined inflammatory wall with minimal or no necrosis. The diagnosis cannot be made prior to 4 wk after the onset of pancreatitis. The clinical presentation is often nonspecific, with abdominal pain being the most common symptom. If a diagnosis is suspected, contrast-enhanced computed tomography and/or magnetic resonance imaging are performed to confirm the diagnosis and assess the characteristics of the pseudocyst. Endoscopic ultrasound with cyst fluid analysis can be performed in cases of diagnostic uncertainty. Pseudocyst of the pancreas can lead to complications such as hemorrhage, infection, and rupture. The management of pancreatic pseudocysts depends on the presence of symptoms and the development of complications, such as biliary or gastric outlet obstruction. Management options include endoscopic or surgical drainage. The aim of this review was to summarize the current literature on pancreatic pseudocysts and discuss the evolution of the definitions, diagnosis, and management of this condition.

Disconnected pancreatic duct syndrome. Endoscopic approach

Disconnected pancreatic duct syndrome (DPCS) is due to disruption of the main pancreatic duct (PC) or its secondary branches, a complication present in 30-80% of acute necrotizing pancreatitis. The secretion of pancreatic enzymes by isolated functioning pancreatic tissue can facilitate the recurrence of encapsulated necrotic collections, so its endoscopic management remains a controversial issue in daily practice. We present a case of disconnected pancreatic duct syndrome resolved after placement of a pancreatic stent.

Guessing the future of endoscopic drainage of walled-off necrosis

The endoscopic treatment of walled-off necrosis is rapidly evolving concurrently with an increasing number of endoscopic techniques, devices, and combined procedures. Thus, there is a growing armamentarium of alternatives for those patients in whom the conventional direct endoscopic necrosectomy is not enough. However, when the patient reaches this point he enters in an unexplored field and choosing the correct option can be challenging. Furthermore, there is no consensus on the number of endoscopic procedures to perform before considering that direct endoscopic necrosectomy has failed and therefore another strategy should be considered.