Pancreatic necrosis occurs in about 20% of patients with acute pancreatitis, and about 30% of them develop secondary infection. Inflammatory pancreatic fluid collections (PFCs) are considered to be adverse events resulting from acute and chronic pancreatitis, pancreatic trauma, and pancreatic surgery. Cystic neoplasms of the pancreas are also often misdiagnosed as inflammatory PFCs due to similarities in imaging presentation, so it is important to correctly diagnose and manage inflammatory PFCs.
The 2012 Atlanta classification classifies inflammatory PFCs as acute peripancreatic fluid, pancreatic pseudocysts, acute necrotic accumulation and encapsulated necrosis (WON). For the management of these local complications of acute pancreatitis, most of them have been treated by surgery or percutaneous puncture in the past. With the development of medical technology, endoscopic non-invasive diagnosis and treatment are gaining more and more attention.
The guidelines recommend the preparation of endoscopic drainage before the procedure
1. Discontinue all anticoagulation and antiplatelet aggregation drugs except low-dose aspirin to avoid causing intraoperative bleeding;
2. Ensure immediate preparation for effective radiological intervention to stop bleeding or surgical intervention in the event of acute bleeding and perforation;
3. Intraoperative deep sedation or anesthesia is recommended;
4. To minimize the risk of gas embolism, it is recommended to apply carbon dioxide insufflation;
5. It is recommended to apply antimicrobial drugs prophylactically to patients, especially WON patients.
The main recommendations of the guidelines
Endoscopic drainage of inflammatory PFCs is recommended after effective exclusion of possible diagnoses such as pancreatic cystic tumors and pseudoaneurysms (high quality).
Endoscopic intervention is recommended only after the inflammatory PFCs have formed a mature cyst wall (more than 4 weeks after onset) (moderate quality).
Drainage of symptomatic pancreatic pseudocysts (medium quality) is recommended.
Drainage of rapidly enlarging pancreatic pseudocysts (low quality) is recommended.
5. Endoscopic drainage is recommended for all patients with infected PFCs that have failed to respond to conservative treatment (high quality).
6. It is recommended to drain PFCs for more than 8 weeks after an episode of acute pancreatitis (moderate quality).
7. Ultrasound-guided fine-needle aspiration of inflammatory PFCs is not required routinely in the diagnosis of infected necrosis (low quality).
8, For pancreatic pseudocysts, endoscopic drainage is recommended as the preferred treatment rather than surgical drainage (medium quality).
When portal hypertension or inadequate intraluminal distension is suspected, ultrasound endoscopic drainage of inflammatory PFCs is recommended (high quality).
10. Endoscopic transmural and/or percutaneous percutaneous drainage is recommended over endoscopic transmural necrosis removal or surgical drainage for patients with WON (medium quality).
11. Endoscopic drainage of inflammatory PFCs is recommended in the presence of surgical and radiological interventions (high quality).
12. Carbon dioxide insufflation of the GI tract (low quality) is recommended during transmural drainage.