Download PDF
CC BY-NC-ND 4.0 · Journal of Digestive Endoscopy 2021; 12(01): 003-010
DOI: 10.1055/s-0041-1728956
Guidelines

Endoscopic Management of Pancreatic Fluid Collections: Guidelines of Society of Gastrointestinal Endoscopy of India and Indian EUS Club

Rahul Shah
1   Department of Gastroenterology, Institute of Digestive and Liver Care, SL Raheja Hospital, Mumbai, Maharashtra, India
,
Jahangeer Basha
2   Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
,
Surinder Rana
3   Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
,
Soumya Jagannath
4   Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
,
Praveer Rai 
5   Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute, Lucknow, Uttar Pradesh, India
,
Sudipta Dhar Chowdhury 
6   Department of Gastroenterology, Christian Medical College, Vellore, Tamil Nadu, India
,
Zubin Dev Sharma
7   Department of Gastroenterology, Medanta The Medicity, Gurugram, Haryana, India
,
Deepak Gunjan 
4   Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
,
Saurabh Patle
7   Department of Gastroenterology, Medanta The Medicity, Gurugram, Haryana, India
,
A Chalapathi Rao 
8   Department of Gastroenterology, Iconkrishi Institute of Medical Sciences, Vishakhapatnam, Andhra Pradesh, India
,
Prakash Zacharia
9   Department of Gastroenterology, Lisie Hospital, Kochi, Kerala, India
,
Rajesh Sanjeevi
6   Department of Gastroenterology, Christian Medical College, Vellore, Tamil Nadu, India
,
Manoj Sahu 
10   Department of Gastroenterology, Institute of Medical Sciences and Sum Hospital, Bhubaneshwar, Odisha, India
,
Matthew Philip
9   Department of Gastroenterology, Lisie Hospital, Kochi, Kerala, India
,
Pramod Garg
4   Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
,
Rajesh Puri
7   Department of Gastroenterology, Medanta The Medicity, Gurugram, Haryana, India
,
D Nageshwar Reddy
2   Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
,
Sundeep Lakhthakia
,
Vinay Dhir
1   Department of Gastroenterology, Institute of Digestive and Liver Care, SL Raheja Hospital, Mumbai, Maharashtra, India
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Introduction

The endoscopic management of pancreatic fluid collections (PFC) is in flux due to changes in how we classify them, as well as rapid advances in technology. The revised Atlanta classification of PFC[1] clearly distinguished pseudocysts from walled-off necrosis (WON) and acute peri PFC from acute necrotic collections, based upon presence of necrosis, time since the onset of attack of pancreatitis and formation of a mature wall around the fluid collection. The literature prior to this had both, a mix of WON and pseudocyst, usually labeled as pseudocysts.[1] [2] The subsequent publications have clearly demonstrated that the management issues are different for pseudocyst and WON, although clarity still eludes several areas. Another major development has been the application of biflanged metal (BFMS) and lumen apposing metal stents (LAMS) for PFC. Despite a lot of literature available for BFMS and LAMS, controversies still exist about their appropriate role. The Society of Gastrointestinal Endoscopy of India and Indian endoscopic ultrasound (EUS) club developed these guidelines to conduct an updated literature review, and provide recommendations based upon strength of available evidence.[3]



Publication History

Article published online:
17 April 2021

© 2021. Society of Gastrointestinal Endoscopy of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Banks PA, Bollen TL, Dervenis C. et al. Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62 (01) 102-111
    CrossrefPubMedGoogle Scholar
  • 2 Dhir V, Maydeo A. EUS-guided pseudocyst drainage: has the metal proved its mettle. ? Gastrointest Endosc 2015; 82 (05) 828-830
    CrossrefPubMedGoogle Scholar
  • 3 Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Developing clinical guidelines. West J Med 1999; 170 (06) 348-351
    PubMedGoogle Scholar
  • 4 Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13 (04) e1-e15
    CrossrefPubMedGoogle Scholar
  • 5 Muthusamy VR, Chandrasekhara V, Acosta RD. et al. ASGE Standards of Practice Committee. The role of endoscopy in the diagnosis and treatment of inflammatory pancreatic fluid collections. Gastrointest Endosc 2016; 83 (03) 481-488
    CrossrefPubMedGoogle Scholar
  • 6 Arvanitakis M, Dumonceau JM, Albert J. et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy 2018; 50 (05) 524-546
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Varadarajulu S, Christein JD, Tamhane A, Drelichman ER, Wilcox CM. Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos). Gastrointest Endosc 2008; 68 (06) 1102-1111
    CrossrefPubMedGoogle Scholar
  • 8 Park DH, Lee SS, Moon SH. et al. Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial. Endoscopy 2009; 41 (10) 842-848
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Varadarajulu S, Wilcox CM, Tamhane A, Eloubeidi MA, Blakely J, Canon CL. Role of EUS in drainage of peripancreatic fluid collections not amenable for endoscopic transmural drainage. Gastrointest Endosc 2007; 66 (06) 1107-1119
    CrossrefPubMedGoogle Scholar
  • 10 Trikudanathan G, Tawfik P, Amateau SK. et al. Early (<4 Weeks) versus standard (≥ 4 Weeks) endoscopically centered step-up interventions for necrotizing pancreatitis. Am J Gastroenterol 2018; 113 (10) 1550-1558
    CrossrefPubMedGoogle Scholar
  • 11 Rana SS, Gupta R. Endoscopic transluminal drainage in the early phase of acute necrotising pancreatitis. Am J Gastroenterol 2019; 114 (04) 688-689
    CrossrefPubMedGoogle Scholar
  • 12 Patel R, Gardner TB. Early versus late necrotic pancreatic fluid collection drainage: does timing make a difference. ? Gastrointest Endosc 2020; 91 (06) 1310-1311
    CrossrefPubMedGoogle Scholar
  • 13 Chantarojanasiri T, Yamamoto N, Nakai Y. et al. Comparison of early and delayed EUS-guided drainage of pancreatic fluid collection. Endosc Int Open 2018; 6 (12) E1398-E1405
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Oblizajek N, Takahashi N, Agayeva S. et al. Outcomes of early endoscopic intervention for pancreatic necrotic collections: a matched case-control study. Gastrointest Endosc 2020; 91 (06) 1303-1309
    CrossrefPubMedGoogle Scholar
  • 15 Bang JY, Arnoletti JP, Holt BA. et al. An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis. Gastroenterology 2019; 156 (04) 1027-1040.e3
    CrossrefPubMedGoogle Scholar
  • 16 Rana SS, Verma S, Kang M, Gorsi U, Sharma R, Gupta R. Comparison of endoscopic versus percutaneous drainage of symptomatic pancreatic necrosis in the early (<4 weeks) phase of illness. Endosc Ultrasound 2020; 9 (06) 402-409
    CrossrefPubMedGoogle Scholar
  • 17 Garg PK, Meena D, Babu D. et al. Endoscopic versus laparoscopic drainage of pseudocyst and walled-off necrosis following acute pancreatitis: a randomized trial. Surg Endosc 2020; 34 (03) 1157-1166
    CrossrefPubMedGoogle Scholar
  • 18 Teoh AYB, Dhir V, Jin ZD, Kida M, Seo DW, Ho KY. Systematic review comparing endoscopic, percutaneous and surgical pancreatic pseudocyst drainage. World J Gastrointest Endosc 2016; 8 (06) 310-318
    CrossrefPubMedGoogle Scholar
  • 19 Teoh AYB, Ho LKY, Dhir VK. et al. A multi-institutional survey on the practice of endoscopic ultrasound (EUS) guided pseudocyst drainage in the Asian EUS group. Endosc Int Open 2015; 3 (02) E130-E133
    PubMedGoogle Scholar
  • 20 Morgan DE, Baron TH, Smith JK, Robbin ML, Kenney PJ. Pancreatic fluid collections prior to intervention: evaluation with MR imaging compared with CT and US. Radiology 1997; 203 (03) 773-778
    CrossrefPubMedGoogle Scholar
  • 21 Isenmann R, Rünzi M, Kron M. et al. German Antibiotics in Severe Acute Pancreatitis Study Group. Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial. Gastroenterology 2004; 126 (04) 997-1004
    CrossrefPubMedGoogle Scholar
  • 22 Pederzoli P, Bassi C, Vesentini S, Campedelli A. A randomized multicenter clinical trial of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem. Surg Gynecol Obstet 1993; 176 (05) 480-483
    PubMedGoogle Scholar
  • 23 Varadarajulu S, Tamhane A, Blakely J. Graded dilation technique for EUS-guided drainage of peripancreatic fluid collections: an assessment of outcomes and complications and technical proficiency (with video). Gastrointest Endosc 2008; 68 (04) 656-666
    CrossrefPubMedGoogle Scholar
  • 24 Gornals JB, Perez-Miranda M, Vazquez-Sequeiros E. et al. Spanish Working Group on Pancreatic Collection Therapy. Multicenter study of plastic vs. self-expanding metal stents in endoscopic ultrasound-guided drainage of walled-off pancreatic necrosis - PROMETHEUS: a randomized controlled trial protocol. Trials 2019; 20 (01) 791
    CrossrefPubMedGoogle Scholar
  • 25 Lin H, Zhan XB, Sun SY. et al. Stent selection for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a multicenter study in china. Gastroenterol Res Pract 2014; 2014: 193562 DOI: 10.1155/2014/193562.
    CrossrefPubMedGoogle Scholar
  • 26 Bang JY, Hawes R, Bartolucci A, Varadarajulu S. Efficacy of metal and plastic stents for transmural drainage of pancreatic fluid collections: a systematic review. Dig Endosc 2015; 27 (04) 486-498
    CrossrefPubMedGoogle Scholar
  • 27 Ang TL, Kongkam P, Kwek ABE, Orkoonsawat P, Rerknimitr R, Fock KM. A two-center comparative study of plastic and lumen-apposing large diameter self-expandable metallic stents in endoscopic ultrasound-guided drainage of pancreatic fluid collections. Endosc Ultrasound 2016; 5 (05) 320-327
    CrossrefPubMedGoogle Scholar
  • 28 Mukai S, Itoi T, Baron TH. et al. Endoscopic ultrasound-guided placement of plastic vs. biflanged metal stents for therapy of walled-off necrosis: a retrospective single-center series. Endoscopy 2015; 47 (01) 47-55
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Siddiqui AA, Kowalski TE, Loren DE. et al. Fully covered self-expanding metal stents versus lumen-apposing fully covered self-expanding metal stent versus plastic stents for endoscopic drainage of pancreatic walled-off necrosis: clinical outcomes and success. Gastrointest Endosc 2017; 85 (04) 758-765
    CrossrefPubMedGoogle Scholar
  • 30 Bang JY, Wilcox CM, Trevino JM. et al. Relationship between stent characteristics and treatment outcomes in endoscopic transmural drainage of uncomplicated pancreatic pseudocysts. Surg Endosc 2014; 28 (10) 2877-2883
    CrossrefPubMedGoogle Scholar
  • 31 Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association Clinical Practice Update: management of pancreatic necrosis. Gastroenterology 2020; 158 (01) 67-75.e1
    CrossrefPubMedGoogle Scholar
  • 32 Thompson CC, Kumar N, Slattery J. et al. A standardized method for endoscopic necrosectomy improves complication and mortality rates. Pancreatology 2016; 16 (01) 66-72
    CrossrefPubMedGoogle Scholar
  • 33 Bang JY, Navaneethan U, Hasan MK, Sutton B, Hawes R, Varadarajulu S. Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomised trial. Gut 2019; 68 (07) 1200-1209
    CrossrefPubMedGoogle Scholar
  • 34 Mohan BP, Jayaraj M, Asokkumar R. et al. Lumen apposing metal stents in drainage of pancreatic walled-off necrosis, are they any better than plastic stents? A systematic review and meta-analysis of studies published since the revised Atlanta classification of pancreatic fluid collections. Endosc Ultrasound 2019; 8 (02) 82-90
    CrossrefPubMedGoogle Scholar
  • 35 Tan S, Zhong C, Ren R. et al. Are Lumen-Apposing Metal Stents More Effective Than Plastic Stents for the Management of Pancreatic Fluid Collections: An Updated Systematic Review and Meta-analysis. Hindawi Gastroenterology Research and Practice.. Volume London, UK: 2020
    Google Scholar
  • 36 Saunders R, Ramesh J, Cicconi S. et al. A systematic review and meta-analysis of metal versus plastic stents for drainage of pancreatic fluid collections: metal stents are advantageous. Surg Endosc 2019; 33 (05) 1412-1425
    CrossrefPubMedGoogle Scholar
  • 37 Navaneethan U, Njei B, Sanaka MR. Endoscopic transmural drainage of pancreatic pseudocysts: multiple plastic stents versus metal stents: a systematic review and meta-analysis. Gastrointest Endosc 2014; 79: AB167-AB168
    CrossrefGoogle Scholar
  • 38 Yoon SB, Lee IS, Choi MG. Metal versus plastic stents for drainage of pancreatic fluid collection: a meta-analysis. United European Gastroenterol J 2018; 6 (05) 729-738
    CrossrefPubMedGoogle Scholar
  • 39 Chen YI, Yang J, Friedland S. et al. Lumen apposing metal stents are superior to plastic stents in pancreatic walled-off necrosis: a large international multicenter study. Endosc Int Open 2019; 7 (03) E347-E354
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Teoh AYB, Bapaye A, Lakhtakia S. et al. Prospective multicenter international study on the outcomes of a newly developed self-approximating lumen-apposing metallic stent for drainage of pancreatic fluid collections and endoscopic necrosectomy. Dig Endosc 2020; 32 (03) 391-398
    CrossrefPubMedGoogle Scholar
  • 41 Aburajab M, Smith Z, Khan A, Dua K. Safety and efficacy of lumen-apposing metal stents with and without simultaneous double-pigtail plastic stents for draining pancreatic pseudocyst. Gastrointest Endosc 2018; 87 (05) 1248-1255
    CrossrefPubMedGoogle Scholar
  • 42 Ali SE, Benrajab K, Mardini H, Su L, Gabr M, Frandah WM. Anchoring lumen-apposing metal stent with coaxial plastic stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: any benefit?. Ann Gastroenterol 2019; 32 (06) 620-625
    PubMedGoogle Scholar
  • 43 Puga M, Consiglieri CF, Busquets J. et al. Safety of lumen-apposing stent with or without coaxial plastic stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a retrospective study. Endoscopy 2018; 50 (10) 1022-1026
    Article in Thieme ConnectPubMedGoogle Scholar
  • 44 Lakhtakia S, Basha J, Talukdar R. et al. Endoscopic “step-up approach” using a dedicated biflanged metal stent reduces the need for direct necrosectomy in walled-off necrosis (with videos). Gastrointest Endosc 2017; 85 (06) 1243-1252
    CrossrefPubMedGoogle Scholar
  • 45 Rana SS, Sharma V, Sharma R, Gupta R, Bhasin DK. Endoscopic ultrasound guided transmural drainage of walled off pancreatic necrosis using a “step - up” approach: a single centre experience. Pancreatology 2017; 17 (02) 203-208
    CrossrefPubMedGoogle Scholar
  • 46 van Brunschot S, van Grinsven J, van Santvoort HC. et al. Dutch Pancreatitis Study Group. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391 (10115) 51-58
    CrossrefPubMedGoogle Scholar
  • 47 Elmunzer BJ. Endoscopic drainage of pancreatic fluid collections. Clin Gastroenterol Hepatol 2018; 16 (12) 1851-1863.e3
    CrossrefPubMedGoogle Scholar
  • 48 van Brunschot S, Fockens P, Bakker OJ. et al. Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review. Surg Endosc 2014; 28 (05) 1425-1438
    CrossrefPubMedGoogle Scholar
  • 49 Yan L, Dargan A, Nieto J. et al. Direct endoscopic necrosectomy at the time of transmural stent placement results in earlier resolution of complex walled-off pancreatic necrosis: results from a large multicenter United States trial. Endosc Ultrasound 2019; 8 (03) 172-179
    CrossrefPubMedGoogle Scholar
  • 50 Puli SR, Graumlich JF, Pamulaparthy SR, Kalva N. Endoscopic transmural necrosectomy for walled-off pancreatic necrosis: a systematic review and meta-analysis. Can J Gastroenterol Hepatol 2014; 28 (01) 50-53
    CrossrefPubMedGoogle Scholar
  • 51 Messallam AA, Adler DG, Shah RJ. et al. Direct endoscopic necrosectomy with and without hydrogen peroxide for walled-off pancreatic necrosis: a multicenter comparative study. Am J Gastroenterol 2020; DOI: 10.14309/ajg.0000000000000987.
    CrossrefPubMedGoogle Scholar
  • 52 Tamura T, Itonaga M, Tanioka K. et al. Radical treatment for walled-off necrosis: transmural nasocyst continuous irrigation. Dig Endosc 2019; 31 (03) 307-315
    CrossrefPubMedGoogle Scholar
  • 53 Arvanitakis M, Delhaye M, Bali MA. et al. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007; 65 (04) 609-619
    CrossrefPubMedGoogle Scholar
  • 54 Rana SS, Bhasin DK, Rao C, Sharma R, Gupta R. Consequences of long term indwelling transmural stents in patients with walled off pancreatic necrosis & disconnected pancreatic duct syndrome. Pancreatology 2013; 13 (05) 486-490
    CrossrefPubMedGoogle Scholar
  • 55 Dhir V, Adler DG, Dalal A, Aherrao N, Shah R, Maydeo A. Early removal of biflanged metal stents in the management of pancreatic walled-off necrosis: a prospective study. Endoscopy 2018; 50 (06) 597-605
    Article in Thieme ConnectPubMedGoogle Scholar
  • 56 Dhir V, Teoh AY, Bapat M, Bhandari S, Joshi N, Maydeo A. EUS-guided pseudocyst drainage: prospective evaluation of early removal of fully covered self-expandable metal stents with pancreatic ductal stenting in selected patients. Gastrointest Endosc 2015; 82 (04) 650-657
    CrossrefPubMedGoogle Scholar
  • 57 Bang JY, Mel Wilcox C, Arnoletti JP, Varadarajulu S. Importance of disconnected pancreatic duct syndrome in recurrence of pancreatic fluid collections initially drained using lumen-apposing metal stents. Clin Gastroenterol Hepatol 2020; S1542-3565 (20) 30984-30988
    Google Scholar
  • 58 Basha J, Lakhtakia S, Nabi Z. et al. Impact of disconnected pancreatic duct on recurrence of fluid collections and new-onset diabetes: do we finally have an answer?. Gut 2021; 70 (03) 447-449
    CrossrefPubMedGoogle Scholar
  • 59 Varadarajulu S, Wilcox CM. Endoscopic placement of permanent indwelling transmural stents in disconnected pancreatic duct syndrome: does benefit outweigh the risks. ? Gastrointest Endosc 2011; 74 (06) 1408-1412
    CrossrefPubMedGoogle Scholar
  • 60 Telford JJ, Farrell JJ, Saltzman JR. et al. Pancreatic stent placement for duct disruption. Gastrointest Endosc 2002; 56 (01) 18-24
    CrossrefPubMedGoogle Scholar
  • 61 Varadarajulu S, Noone TC, Tutuian R, Hawes RH, Cotton PB. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc 2005; 61 (04) 568-575
    CrossrefPubMedGoogle Scholar
  • 62 Trevino JM, Tamhane A, Varadarajulu S. Successful stenting in ductal disruption favorably impacts treatment outcomes in patients undergoing transmural drainage of peripancreatic fluid collections. J Gastroenterol Hepatol 2010; 25 (03) 526-531
    CrossrefPubMedGoogle Scholar
  • 63 Yang D, Amin S, Gonzalez S. et al. Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study. Gastrointest Endosc 2016; 83 (04) 720-729
    CrossrefPubMedGoogle Scholar
  • 64 Amin S, Yang DJ, Lucas AL, Gonzalez S, DiMaio CJ. There is no advantage to transpapillary pancreatic duct stenting for the transmural endoscopic drainage of pancreatic fluid collections: a meta-analysis. Clin Endosc 2017; 50 (04) 388-394
    CrossrefPubMedGoogle Scholar
  • 65 Wang L, Elhanafi S, Storm AC. et al. Impact of disconnected pancreatic duct syndrome on endoscopic ultrasound-guided drainage of pancreatic fluid collections. Endoscopy 2020; 1213-1489
    Google Scholar