Clinical Gastroenterology and Hepatology 2018;16:1851–1863
NARRATIVE REVIEWS
Endoscopic Drainage of Pancreatic Fluid Collections
B. Joseph Elmunzer
Division of Gastroenterology & Hepatology, Medical University of South Carolina, Charleston, South Carolina
Endoscopy has emerged as a mainstay in the management
of pancreatic fluid collections (PFCs), representing an
important advance in clinical medicine that has signifi-
cantly improved the risk-benefit ratio of treating this
complex patient population. While endoscopic pseudocyst
drainage has generally supplanted surgical and percuta-
neous approaches, the optimal strategy for walled-off ne-
crosis remains variable and multi-disciplinary despite an
emerging trend from randomized trials favoring endos-
copy. Although several issues pertaining to endoscopic
drainage appear to have been settled – such as the use of
endoscopic ultrasound – other pressing questions –
including the optimal prosthesis and debridement
strategy – remain unanswered, and rigorous investigation
is needed. This review aims to provide an evidence-based
but practical appraisal of the endoscopic drainage of
PFCs through the perspective of the author, with an
emphasis on relevant clinical and endoscopic consider-
ations and important research questions.
Keywords: Pancreatic Fluid Collection; Walled-Off Necrosis;
Pseudocyst; Cyst-Gastrostomy; Cyst-Duodenostomy;
Necrosectomy.
ew areas in interventional endoscopy have expe-
F rienced as much growth in the last decade as the
management of inflammatory pancreatic fluid collections
(PFCs). In 2008, endoscopic necrosectomy (EN) was un-
common enough at most institutions that a case would
draw several intrigued observers into the endoscopy
suite. Nowadays, several cases may be performed daily at
referral centers, each in a standard 60- to 90-minute time-
slot. Growing understanding of, and comfort with, these
procedures and important technological advances have
rendered endoscopic drainage a mainstay of PFC manage-
ment, firmly complementing and to a large extent sup-
planting percutaneous and surgical drainage approaches.
Herein is a narrative review of the endoscopic
drainage of PFCs. The content is based on an unstruc-
tured but comprehensive review of the literature, 10
years of experience performing these cases in routine
clinical practice, and extensive discussions with col-
leagues and other recognized experts in the field.
Although I attempt to provide a balanced appraisal of
existing evidence and practice, this review is undoubt-
edly influenced by my personal views and experiences.
An evidence-based guideline document, using formal
systematic review methodology and the GRADE
Fasiha Kanwal, Section Editor
assessment framework, is under development by an in-
ternational multidisciplinary walled-off necrosis (WON)
working group. Additional content pertaining to several
sections of this review is included in the Supplementary
Appendix (Table 1).
Background
Approximately 40% of cases of acute pancreatitis
(AP) are complicated by fluid collections, most of which
resolve spontaneously.1–3 Patients with severe or
moderately severe AP, especially those with pancreatic
necrosis, are much more likely than those with mild
edematous pancreatitis to develop a clinically relevant
PFC.4-6 An acute collection in excess of 5–6 cm in a pa-
tient with severe and/or necrotizing pancreatitis seems
to be the strongest predictor of cyst persistence and need
for treatment.4,5 Excluding a pancreatic cystic neoplasm,
which can occasionally masquerade as an inflammatory
PFC, is of paramount importance because transmural
drainage of such a lesion can result in serious procedural
and oncologic complications. When the diagnosis is un-
certain, such as in the absence of prior pancreatitis and/
or when the aspirate is completely clear (as opposed to
the typical brown color of inflammatory fluid), fluid
analysis for amylase, chorioembryonic antigen, and
cytology before drainage is prudent.
Based on the revised Atlanta consensus classification,
PFCs are divided according to their content and wall
maturity.7 Thus, a collection that contains pure fluid is
classified as an acute peri-PFC within the first 4 weeks
after an attack of AP, and subsequently as a pseudocyst
(PC) if it does not resolve spontaneously. Similarly, a
collection that contains necrotic debris is classified as an
acute necrotic collection in the early phase and subse-
quently as a WON after 4 weeks have passed and the cyst
wall has matured. Necrotic collections may contain
Abbreviations used in this paper: AP, acute pancreatitis; CT, computed
tomography; EN, endoscopic necrosectomy; ERCP, endoscopic retro-
grade cholangiopancreatography; EUS, endoscopic ultrasound; fcSEMS,
fully covered self-expanding metallic stent; GI, gastrointestinal; LAMS,
lumen-apposing metal stent; PC, pseudocyst; PFC, pancreatic fluid
collection; WON, walled-off necrosis.
Most current article
© 2018 by the AGA Institute
1542-3565/$36.00
https://doi.org/10.1016/j.cgh.2018.03.021
1852 B. Joseph Elmunzer
Table 1. Appendix Contents
Transmural drainage before 4 weeks after acute pancreatitis
Transpapillary drainage of walled-off necrosis
Selecting the location of the cyst-gastrostomy or cyst-
duodenostomy
Using multiple guidewires
Duodenoscope for cyst-gastrostomy or cyst-duodenostomy
Additional technical considerations during necrosectomy
Mechanical debridement
Endoscopic placement of transmural stents
Additional considerations pertaining to lumen-apposing metal stents
Maldeployment (video)
Stent dysfunction
Adverse events
Post-procedural imaging and follow-up
pancreatic and/or peripancreatic necrosis, although the
distinction does not directly impact management. This
nomenclature is not only important in standardizing
clinical communication and reporting of research, but
has concrete treatment implications.
General Approach to Management
A general algorithm for the management of PFCs is
presented in Figure 1 and is largely dictated by 3 factors:
(1) whether treatment is clinically indicated, (2) whether
the wall of the collection is mature, and (3) whether the
collection contains necrotic content. Generally speaking,
PFCs only require treatment if they result in symptoms
or compression of critical structures (typically bile duct,
gastrointestinal [GI] tract, or vessel) because the risk of
an iatrogenic complication related to drainage signifi-
cantly exceeds that of a spontaneous complication (eg,
spontaneous infection, bleeding, or rupture).8,9 Within
the first 4 weeks after an attack of pancreatitis, the
process remains in evolution and the wall of the collec-
tion is immature so treatment should be temporized if
Clinical Gastroenterology and Hepatology Vol. 16, No. 12
possible,10,11 usually with pain control, deep enteral
nutrition, and antibiotics if there is clinical suggestion of
infection. The most common reason for failure of con-
servative management in this early phase is refractory
infection, which should initially be addressed by percu-
taneous drainage. Although the decision to proceed with
percutaneous drainage should be thoughtfully consid-
ered because of the risk of a pancreaticocutaneous fis-
tula, a significant delay in drainage when fever persists
despite antibiotic therapy can result in life-threatening
disseminated infection. At this early stage in the man-
agement algorithm, percutaneous drainage is indicated
for both acute peri-PFCs and acute necrotic collections;
however, the distinction has important implications.
First, acute nonnecrotic collections are more likely to
respond to percutaneous drainage alone. Second, if the
collection contains necrotic tissue, the drain should
ideally be placed through a retroperitoneal tract (for
body and tail collections) to facilitate subsequent video-
assisted retroperitoneal debridement if necessary. Oc-
casionally, small (<5 cm) acute collections that require
drainage can be managed via endoscopic retrograde
cholangiopancreatography (ERCP) with transpapillary
stent placement to avoid the risk of fistula.
In cases of infected acute necrotic collections, if the
response to percutaneous drainage and antibiotics is
insufficient, then surgical debridement by video-assisted
retroperitoneal debridement or a minimally invasive
transgastric approach is the next step according to the
step-up philosophy.12 Conventional open surgical
drainage should only be considered when less invasive
measures have been exhausted.13,14
Beyond 3–4 weeks after the attack of AP, endoscopic
treatment plays a primary management role because
mature collections (PC and WON) are amenable to
transmural drainage because they are generally adherent
to the stomach or duodenal wall and their capsule is
organized enough to withstand puncture, dilation, and
Figure 1. General algo-
rithm for the management
of inflammatory pancreatic
fluid collections. ANC,
acute necrotic collection;
APFC, acute peripancre-
atic fluid collection; VARD,
video-assisted retroperito-
neal debridement.
December 2018
endoscopic exploration (Supplementary Appendix). If
treatment can be temporized until this phase, then
percutaneous and surgical drainage can often be
avoided.13,15
Infrastructure
Most units that provide high-quality endoscopic ul-
trasound (EUS) and ERCP services have the requisite
equipment and expertise to perform endoscopic PFC
drainage. Graduates of dedicated advanced endoscopy
fellowship programs in the United States have generally
been exposed to and have some experience with endo-
scopic PFC management techniques. However, given the
complexity of these cases, graduates may not have ac-
quired a great deal of hands-on experience during
training and thus a period of proctoring by more expe-
rienced partners may be necessary.
Expert surgical and interventional radiologic backup,
and a culture of communication and collegiality among
stakeholders is essential for the optimal treatment of this
complex patient population. Although the fraction of
patients undergoing endoscopic drainage who will
require nonendoscopic salvage is thankfully small, effi-
cient surgical or radiologic rescue from serious compli-
cations is occasionally life-saving and a critical safety net.
Ideally, PFC cases would be discussed systematically
in interdisciplinary group fashion to develop the
preferred approach, akin to a tumor board discussion.
However, in a high-throughput clinical practice, routine
structured discussion is not always practical and may
delay efficient care in patients who require real-time
decision-making. At our institution, we communicate
continually with our surgical colleagues about myriad
patients but we do not systematically discuss every PFC
case unless there is uncertainty on the part of 1 or more
parties about the optimal approach. This tends to occur
much more commonly for WON than PC.
Imaging
The primary objective of imaging before endoscopic
drainage is to determine whether the cyst wall is mature
and in close apposition to the GI tract. Additional ob-
jectives of importance include assessing the size and
extent of the collection, evaluating for vascular struc-
tures within or in close proximity to the collection
(including pseudoaneurysms), determining whether the
pancreas remains in continuity or is disconnected, and
differentiating between PC and WON.
Computed tomography (CT) scan is inadequate for
reliably differentiating between PC and WON.16,17 Fea-
tures on CT scan that may suggest WON are (1) larger
collection size, (2) tracking into the paracolic gutters, (3)
irregular wall definition, (4) presence of fat attenuation
debris within the collection, and (5) collection replacing
the middle portion of the gland leading to pancreatic
Pancreatic Fluid Collections 1853
discontinuity,17 with the lattermost being the most
helpful in my experience. Magnetic resonance imaging,
EUS, and even transabdominal ultrasound (in the case of
a large cyst) are all significantly more accurate in
depicting necrosis.16,18 Because drainage is routinely
performed under EUS guidance, the technical approach
(eg, using plastic vs lumen-apposing stent) is usually
based on real-time sonographic assessment of cyst con-
tents. In situations in which performing endoscopic
drainage versus surgery is based solely on the amount of
necrosis within the cyst, preprocedural magnetic reso-
nance imaging provides the most actionable information.
Endoscopic Drainage
Mature PFCs can be drained by transpapillary (ERCP
with pancreatic stent placement) and transmural tech-
niques. In all cases, transmural drainage requires the
creation of a conduit between the gut and the collection
(cyst-gastrostomy or cyst-duodenostomy), but EN in-
volves the additional steps of entering the cavity with a
gastroscope and performing mechanical debridement of
the necrotic content. Transpapillary and transmural
drainage may be used as stand-alone interventions or in
combination.
Transpapillary Drainage as
Primary Therapy
In general, collections smaller than 5 cm in size that
contain fluid only are ideal for treatment via ERCP with
transpapillary pancreatic stent placement
(Supplementary Appendix). Not only are these collec-
tions likely to respond to transpapillary stent placement
alone, they may be too small in terms of working space to
execute the steps needed for transmural drainage. Akin
to any leak management, providing a path of least
resistance for pancreatic juice into the duodenum
through the stent should divert flow away from the cyst,
allowing it to collapse and heal. Limited data suggest that
bridging the pancreatic duct leak with a stent increases
the likelihood of success, which is in contrast to bile leaks
for which transpapillary stent placement alone is often
sufficient.19,20 My approach is to place the largest caliber
stent that fits comfortably within the duct, choosing a
length that bridges the leak and any downstream stric-
ture if possible.
The main risk of transpapillary drainage is secondary
cyst infection caused by the introduction and incomplete
subsequent drainage of contaminated contrast. Thus, an-
tibiotics are typically administered during the procedure
and for several days afterward. Some experts believe that
this risk can be reduced by concurrent EUS-guided (19
gauge) fine-needle aspiration of the cyst to collapse during
the same procedure. This approach has the added benefits
of removing infected fluid if present and alleviating
symptoms more rapidly. However, it remains unclear
1854 B. Joseph Elmunzer
whether these benefits justify the added costs and risks of
EUS fine-needle aspiration in this context.
Transmural Drainage
Observational data suggest that transmural endo-
scopic drainage of PC is associated with durable cyst
resolution in 85%–100% of cases, has an acceptable
safety profile, and compares favorably with surgery in
terms of outcomes and health care resource utiliza-
tion.21,22 A single small, randomized trial comparing
endoscopic with surgical drainage suggested equivalent
treatment success and adverse event rates between the 2
strategies but shorter hospital length of stay, lower costs,
and improved patient-centered outcomes associated
with endoscopic therapy.23 This study has been criticized
because endoscopy was compared with open surgery
rather than the minimally invasive approaches that have
become routine in clinical practice and are likely to
compare more favorably. Nevertheless, endoscopic
drainage is recommended as first-line therapy for pa-
tients with symptomatic pancreatic PC that are anatom-
ically amenable to drainage.24,25 When endoscopic
drainage is used, 2 randomized trials have demonstrated
that an EUS-guided approach to cyst access is more
effective than endoscopy alone.26,27 Furthermore, EUS-
guidance is likely to be safer by avoiding injury to
interceding vessels and other vital structures, although
small trials are unlikely to demonstrate meaningful dif-
ferences in these rare events.
Existing observational and randomized data suggest
that endoscopic treatment of WON is also acceptably
safe and effective.28–30 Two published randomized tri-
als and 1 in press (NCT02084537) suggest that this
approach compares favorably with surgery in terms of
systemic inflammation, complications, and health care
resource utilization.31,32 The TENSION trial, published
in late 2017, demonstrated no difference in the primary
composite endpoint of major complications or death
among 98 patients with infected necrosis that was
amenable to both endoscopic and surgical treatment
options. Subjects in the endoscopy group, however, had
a lower incidence of cardiovascular complications and
pancreaticocutaneous fistulae, and spent an average of
16 fewer days in the hospital with significant associated
cost savings.32 It is important to consider that the
endoscopic step-up approach in this trial (placement of
2 EUS-guided transmural 7F catheter plastic pigtailed
stents followed by EN only if necessary) is less
aggressive than the approach used by many expert
endoscopists (discussed later), which may have miti-
gated the observed benefit in the endoscopy group.
Alternatively, it is noteworthy that this trial was
designed to show superiority of the endoscopic
approach, thus (although the effort to conduct the trial
was herculean) it remains possible that the sample size
was too small to show a benefit in favor of surgery.
Clinical Gastroenterology and Hepatology Vol. 16, No. 12
Surgical Versus Endoscopic
Necrosectomy for Walled-Off Necrosis
Most experts agree, and guidelines support that
endoscopic PC drainage has supplanted surgery in
anatomically amenable cases24,25; however, the
preferred approach to WON remains variable, depending
on patient and collection characteristics and local
expertise. Therapy for WON is typically less successful
and is associated with more complications than PC
drainage,33,34 may require multiple long debridement
sessions, and can be limited by the size and complexity of
the cavity.30,35 Thus until recently, EN was reserved
primarily for infirm patients who are suboptimal surgical
candidates. The aforementioned trials, however, suggest
that EN may be the favored approach for any patient
with an anatomically amenable collection, including
those who are surgically fit. In my practice, patients in
whom I have traditionally favored surgery are younger
and healthier with more complex collections, especially if
they have a disconnected pancreatic tail. In this context, a
1-time operation may be preferred over several endo-
scopic debridement sessions spanning weeks to months,
particularly if the end result is a disconnected gland that
requires surgical treatment anyway (discussed later). I
have occasionally pivoted to surgical necrosectomy after
initiating endoscopic therapy if EN has progressed slowly
in a patient with persistent symptoms or failure to thrive.
Many patients with WON are clinically unwell and
have multiple comorbidities, rendering them suboptimal
candidates for surgery. In these cases, endoscopists and
surgeons typically agree that an initial attempt at endo-
scopic drainage is worthwhile. Among surgically fit pa-
tients with complicated collections, multidisciplinary
discussion remains critical despite the emerging trend
favoring endoscopy.
Technical Considerations for Cyst-
Gastrostomy and Cyst-Duodenostomy
The initial approach to PC and WON is similar in
that a conduit between the GI tract and PFC (cyst-
gastrostomy or cyst-duodenostomy) must first be
established. EUS-guidance to exclude critical interceding
structures and measure the distance between the GI tract
and cyst has become standard practice. The transmural
tract should be devoid of any critical structures and
ideally measure <1 cm.36 Longer tracts can be used,
although the risks are higher and the length must factor
into stent selection. Transmural drainage procedures are
typically performed under general endotracheal anes-
thesia to reduce the risk of aspiration of cyst fluid that
has drained into the upper GI tract.
Traditionally, a 19-gauge fine-needle aspiration nee-
dle is used to puncture into the cyst cavity and aspirate
fluid. A bloody aspirate may suggest the presence of a
recently bleeding pseudoaneurysm that could lead to
December 2018
significant hemorrhage if the tamponade effect of the
cyst is undermined by drainage. Thus, in my practice,
unless the patient has had an antecedent arterial phase
CT scan or the drainage is considered life-saving, initial
aspiration of bloody fluid prompts delay of the proced-
ure until a CT angiogram is obtained to exclude pseu-
doaneurysm. This precaution, however, is not evidence
based and venous bleeding is likely a culprit in most
cases. I do not routinely send fluid for microbiologic
analysis.
After needle puncture, a guidewire is advanced into
and coiled within the cyst under fluoroscopic guidance.
Fluoroscopy is not mandatory for these procedures but
is often used because of its widespread availability and
possible safety benefits. A 0.035-inch wire is sturdier,
improving the pushability of accessories across the cyst
wall, but a 0.025-inch wire permits use of smaller caliber
devices that may be advantageous in initially establishing
a tract through a tough cyst wall. The tract can be
established over the wire using blunt mechanical
dissection or diathermy. As the initial step, a graduated
ERCP dilator (4-5-7F catheter) or dilating balloon cath-
eter are most commonly used to bluntly dissect through
the cyst wall because this technique is often successful
and is probably safer than diathermy (Video 1). Stabi-
lizing the echoendoscope such that it does not deflect
away from the stomach or duodenal wall when
advancing the device across the tract is critical in
achieving adequate pushing force to penetrate through.
Alternatively, the tract may be established using elec-
trosurgical current through a needle knife catheter or
cystotome. In the United States, the only commercially
available cystotome is 10F catheter in caliber, cannot be
advanced over a wire unless the internal contents are
removed, and is not commonly used in clinical practice.
Although the needle knife is more widely used, it is a
suboptimal device for cyst access because the difference
in size between the cutting wire and catheter creates a
step-off that can impede advancement and may increase
the risk of mural or vascular injury if excess force results
in lateral displacement of the needle. The exposed wire
can be bent back along the catheter to create a more
tapered cutting surface.37 A novel electrocautery-
enhanced stent delivery system allows single-device ac-
cess and stent deployment, but commits the endoscopist
to using a specific prosthesis, which may not be the best
choice for that particular case.
Once the tract has been established, it must generally
be dilated over the wire to allow stent placement or
access to the cyst with a gastroscope (Figure 2, Video 2).
This can be accomplished with 1 of many commercially
available ERCP or luminal dilating balloons. Dilation to
4–8 mm is typically adequate to permit plastic or
metallic stent placement, whereas dilation to 15-mm
minimum is necessary to allow access to the cavity
with a standard 9-mm gastroscope. If there is need for a
therapeutic gastroscope or a clear distal attachment,
dilation to 18–20 mm is necessary. Dilation is typically
Pancreatic Fluid Collections 1855
performed sequentially, although there are no data
demonstrating that up-front dilation to the intended size
is more dangerous. Multiple wires can be advanced into
the cyst in parallel to facilitate placement of several
transmural stents (Supplementary Appendix).
All these steps are typically accomplished using a
therapeutic linear array echoendoscope, which has a
channel that is large enough to accommodate any stent.
Some endoscopists prefer to perform the entire proced-
ure under sonographic view, whereas others pivot to
direct endoscopic visualization at some point after initial
wire access is achieved. When it is not possible to bluntly
push a dilating catheter or balloon over the wire into the
cavity under endoscopic visualization, realigning the
wire and device into sonographic view often provides
sufficient mechanical advantage by straightening the
vector of entry. A forward-viewing therapeutic echoen-
doscope featuring a working channel in alignment with
the endoscope shaft is commercially available but not
commonly used and does not seem to be superior to the
standard oblique-viewing instrument.38
Technical Considerations for
Endoscopic Necrosectomy
Although WON can be treated by transmural drainage
alone with or without concurrent irrigation,39–41 some
data and the clinical experience of many experts suggest
that active endoscopic debridement of necrotic content
may increase the likelihood and efficiency of cyst
collapse and resolution (Figure 3, Video 3). Whether to
perform mechanical debridement during the first session
immediately after creating the conduit remains contro-
versial. Some experts favor routine first-session
debridement, whereas others prefer to wait because a
fraction of collections resolve with transmural drainage
alone and necrosis tends to liquefy over time.42–45
Indeed, in the aforementioned TENSION trial, only
about 60% of infected WON required EN even though
transmural drainage was initially achieved with
plastic stents, which are conceptually not expected to
provide robust drainage for necrosis. The amount of
necrosis within the cavity may factor into this decision,
with limited data suggesting that collections containing
<40% necrosis are more likely to resolve without
debridement.46
US clinical practice guidelines recommend stepping
up to direct necrosectomy only if transmural drainage
alone is unsuccessful,25 and several recent narrative re-
views support this approach47-49; however, many ex-
perts consider debridement part and parcel of the initial
treatment strategy because it is reasonably safe and may
reduce time to resolution and resource utilization.50,51
My practice has evolved from large-volume (15 mm)
dilation of the fresh tract to allow first-session direct
necrosectomy (2008–2011), to placement of a biliary
fully covered metal stent (allowing tract maturation and
1856 B. Joseph Elmunzer
softening of the necrosis by gastric acid and pepsin)
followed by dilation and necrosectomy a few days later
(2011–2015), to first-session direct necrosectomy
through a lumen-apposing metal stent (LAMS;
2015–present). Admittedly, the time spent during first-
session EN is variable, based on multiple factors that
include patient stability, the characteristics of the
necrotic debris (progress made), and the status of the
endoscopy schedule. Because decanting the infected fluid
component of the collection is typically the critical
intervention that results in initial clinical improvement,
there is probably no clear mandate to perform EN during
the first session. Data comparing the effectiveness of
these strategies are greatly needed.
Endoscopic debridement involves detaching and
removing pieces of necrosis from the cavity. This is
accomplished by using 1 of many accessories including
foreign body graspers, polypectomy snares, retrieval
Figure 3. Endoscopic
debridement of necrotic
cyst content.
Clinical Gastroenterology and Hepatology Vol. 16, No. 12
Figure 2. Balloon dilation
of the transmural tract.
nets, and lithotripsy baskets. Although graspers can be
particularly helpful when there is limited working space
(especially the 2-pronged coin grasper), snares serve as
the workhorse in my practice. The size of the snare can
be varied based on cyst and necrosis characteristics and
snares are less traumatic than graspers in the event they
are inadvertently opened against the cyst wall. In addi-
tion, diathermy can be delivered through the snare to
transect large pieces of difficult to detach necrosis as
long as one is certain that the cyst wall, vascular struc-
tures, or viable pancreas are not in proximity to the
snare (Video 4).
Adjunct chemical debridement by transcatheter or
endoscopic instillation of several hundred milliliters of
3% hydrogen peroxide solution at a 1:5-1:20 dilution has
been suggested in case series to improve efficiency,52,53
but is not universally used because of the absence of
comparative data and the theoretical risks of bleeding
December 2018
and embolic phenomena.54 I have used hydrogen
peroxide primarily in small cavities with insufficient
working space to grasp necrosis, although with under-
whelming success. Some endoscopists recommend
cessation of acid-suppressive therapy to promote disso-
lution of the necrosis by gastric acid, although supportive
data currently exist in abstract form only.
If an endoscopic step-up strategy is used, concurrent
irrigation through a nasocystic or percutaneous catheter
seems to improve ouctomes.40,41,55 The multiple gateway
technique creates several conduits, allowing nasocystic
irrigation through one and egress of fluid and necrotic
materials through the others. Similarly, dual-modality
transmural plus percutaneous drainage has also been
shown to avoid endoscopic or surgical necrosectomy
with a low risk of pancreaticocutaneous fistula and
reduced costs, because LAMSs do not seem to be
necessary for this approach.56 These strategies are
effective but add inconvenience and risk associated with
creating additional conduits and catheter placement.
Because I have traditionally favored up-front necrosec-
tomy, nasocystic and percutaneous drainage have played
a limited role in my practice, reserved respectively for
recalcitrant cyst infection despite aggressive debride-
ment or unreachable infected portions of the collection
(Figure 4). The comparative risk-benefit ratio of up-front
versus step-up necrosectomy and the role of adjunctive
irrigation/drainage strategies should constitute the next
phase of rigorous investigation in this space.
Stent Selection
Maintenance of the transmural tract has traditionally
been accomplished with 1 or more double-pigtail plastic
stents. Recently, however, metallic stents have become
more popular for this indication because the deployment
of 1 fully covered self-expanding metallic stent (fcSEMS)
is generally more efficient and perhaps safer than placing
multiple plastic stents (Figure 5). In addition, the larger
lumen of the metallic stent enhances drainage and may
Figure 4. Percutaneous
drainage of a discon-
nected section of a ne-
crosis cavity not within
endoscopic reach. (A)
Compartment of infected
walled-off necrosis (short
arrow) that had become
disconnected from the
main cavity (long arrow).
(B) This compartment was
drained percutaneously
(arrow) after endoscopic
debridement of the main
cavity.
Pancreatic Fluid Collections 1857
reduce the risk of occlusion and secondary infection.
These benefits must be weighed against the potential
risks of migration and bleeding, and the substantial cost
of the metallic prosthesis. A small pilot randomized
controlled trial showed shorter procedure times associ-
ated with fcSEMS but no difference in outcomes,57
whereas a larger retrospective comparative effective-
ness study demonstrated that biliary fcSEMS improved
clinical outcomes and reduced adverse events in 230
patients with PC across 2 medical centers in the United
States.58 Whether this observation will be rigorously
confirmed, and whether the benefit of biliary fcSEMS will
apply to WON (in which the necrotic tissue may not
drain through any prosthesis), remains to be seen. My
primary approach is to use biliary fcSEMS with
anchoring flanges for PC, unless there is a disconnected
pancreatic segment that requires long-term transmural
drainage, in which case I favor plastic stents (discussed
later).
The most intriguing innovation in this area has been
the LAMS, a fully covered metallic prosthesis in the shape
of a dumbbell with anchoring flanges on either side of a
saddle.59 An electrocautery enhanced access and
deployment platform allows near simultaneous cyst
puncture and stent deployment using the same delivery
system. The large-caliber lumen of the stent allows
seamless introduction of an endoscope into the cyst and
may facilitate spontaneous egress of necrotic debris.
Several recent observational studies have demonstrated
the feasibility and safety of this device.60–64 The access
platform reduces the number of steps necessary to
create and establish a transmural tract, making the
procedure more efficient and perhaps safer (fewer steps
that may result in an adverse event). Furthermore, large-
caliber balloon dilation of the tract to allow endoscopic
entry into the cyst seems safer within the lumen of the
LAMS (which could seal small perforations and tampo-
nade bleeding vessels) than within a freshly created
tract.
A recent multicenter retrospective study demon-
strated that fcSEMS and LAMS are superior to plastic
1858 B. Joseph Elmunzer
stents for WON, and that the number of procedures
needed for cyst resolution was lowest with LAMS.65
Another recent observational study showed that LAMS
reduces the need for direct necrosectomy compared with
plastic stents.44 However, emerging data are conflict-
ing66,67 and additional rigorous comparative effective-
ness studies are necessary to justify the widespread
adoption of LAMS, the safety and efficacy profile of which
is not fully understood and the cost of which is high.
These data are particularly important for PC for which
endoscopic access to the cyst cavity is unnecessary and
therefore the costs and potential risks of the device may
not be justified. I place LAMS only when I intend to enter
the cyst cavity for debridement. The distinctive nature of
LAMS compared with other stents in terms of shape and
deployment presents some unique considerations per-
taining to maldeployment, occlusion, and other compli-
cations that are outlined in the Supplementary Appendix.
Transpapillary Drainage as
Adjunctive Therapy
An unknown but presumably sizeable fraction of
PFCs are associated with a persistent leak or disruption
of the pancreatic duct that feeds the collection. In these
cases, the PFC may not fully resolve or may recur despite
transmural drainage unless source control is achieved by
adjunctive transpapillary stent placement. It has been
observed, however, that transmural stent placement
alone is sufficient and preferable because cyst collapse
itself may provide mechanical closure of the leak and
ERCP adds risk. Furthermore, some PFCs are no longer in
communication with the pancreatic duct once they
become mature. Existing data comparing transmural
drainage alone with combination therapy are conflict-
ing68,69 but may suggest that there is no incremental
benefit associated with pancreatic stent placement.70,71
Clinical Gastroenterology and Hepatology Vol. 16, No. 12
Figure 5. Fully covered
metal stent placed across
transmural tract.
However, these findings should be interpreted with
caution because the decision to perform ERCP in these
observational studies was inherently nonrandom and
patients with more complicated anatomy who were
destined to experience worse outcomes were perhaps
more likely to undergo ERCP, leading to the apparent
association between ERCP and a lower odds of cyst
resolution.
Although recent data support the concept that not
every PFC requires adjunctive transpapillary drainage
because many resolve durably with cyst collapse alone,
some collections do mandate ductal source control. For
example, PC associated with obstructive chronic
pancreatitis, PFCs that develop after distal pancreatec-
tomy, and nonresolving collections are all conditions for
which pancreatic stent placement is likely to be benefi-
cial. In other less obvious situations, the role of pan-
creatogram remains unclear. Better understanding of
the clinical and radiographic predictors of a persistent
leak and the role of magnetic resonance chol-
angiopancreatography in clinical decision-making is
needed. My practice has evolved from ERCP with stent
placement in almost every patient who undergoes
transmural drainage (not necessarily during the first
procedure) to a more nuanced approach, although many
still undergo an ERCP at some point in the treatment
pathway.
Disconnected Pancreatic Duct
A disconnected pancreatic duct has been observed in
30%–50% of patients with WON.72–74 The gland up-
stream of the disruption continues to secrete pancreatic
juice, generally leading to PFC recurrence and/or
symptoms, such as abdominal pain or recurrent AP
(disconnected pancreatic duct syndrome) unless a long-
term solution is implemented. Transpapillary stent
December 2018 Pancreatic Fluid Collections 1859

placement into the disconnected upstream segment is
generally unsuccessful, but given the implications an
attempt may be worthwhile if the gap is reasonable
because successful bridging can occur (Figure 6).19,75,76
If the disconnected upstream duct is not initially opaci-
fied, placement of a transpapillary stent into the
disruption occasionally results in sufficient collapse of
the cavity around the stent to restore ductal continuity at
the time of follow-up ERCP, but this approach is not
evidence-based and some endoscopists prefer to place a
stent in the downstream duct. The definitive treatment of
this condition is surgery to drain or remove the discon-
nected segment; however, the operation can be morbid
and removal of additional pancreatic parenchyma can
lead to diabetes. Concurrent islet autotransplantation
may reduce the incidence and severity of this
complication.77
An alternative to surgery is placement of transmural
double-pigtail plastic stents into the residual PFC cavity
to provide a long-term conduit for pancreatic juice into
the lumen of the GI tract. Preliminary studies have
demonstrated favorable outcomes associated with this
approach, although data are limited.74,78–82 In some pa-
tients, the disconnected pancreatic segment atrophies or
the tract fully matures (and is maintained by the flow of
pancreatic juice), obviating long-term transmural stent-
ing. However, observational and randomized data sug-
gest lower PFC recurrence rates if transmural stents
remain in situ.82,83 Because the long-term natural history
of stented disconnected pancreatic duct and the risks of
permanent plastic stent placement remain unknown,
comparative data relative to surgery are needed to refine
decision-making among fit surgical candidates.
Complications
Complications related to endoscopic drainage occur
in 5%–20% of patients with PC and 10%–40% of pa-
tients with WON.21,33 These comprise infection, bleeding,
perforation, and pancreatitis if an ERCP is performed.
Cyst infection is almost always the result of inadequate
drainage caused by stent dysfunction or a jailed off
compartment within the cavity. This may occur regard-
less of the size of the prosthesis or the stenting strategy,
and underlies the rationale for periprocedural antibi-
otics. Secondary or worsening cyst infection can gener-
ally be managed by repeat endoscopy to re-establish
continuity between the cavity and GI tract, although
debridement of additional necrosis is advisable if this
was culprit in the obstruction. Increasing or upsizing
stents, or placing additional pigtailed stents through a
LAMS, are all reasonable options to prevent recurrence.
Bleeding complicates up to 20% of cases30 and may
be more common with LAMS.84 Because bleeding may be
caused by a new pseudoaneurysm that is the result of a

Figure 6. Successful
bridging of a disconnected
pancreatic duct during
ERCP. (A) Coronal CT im-
age showing a discon-
nected pancreas (short
arrow) upstream of a WON
(long arrow). (B) Pan-
creatogram revealing
extravasation of contrast
(arrow) into the WON
without filling of the up-
stream duct. (C) After
placement of a fully
covered SEMS (long ar-
row) to provide trans-
papillary drainage of the
WON cavity in the head,
the upstream discon-
nected duct is cannulated
by trial and error (short ar-
row). (D) A plastic pancre-
atic stent is placed
through the SEMS into the
upstream duct completely
bridging the disruption.
1860 B. Joseph Elmunzer
stent-induced arterial injury, significant hemorrhage
should first be evaluated with a CT angiogram even if a
prior study was negative. The presence of a pseudoa-
neurysm should prompt angiographic embolization.
Bleeding may also occur from the transmural tract or
venous structures within or adjacent to the cyst cavity.
This type of bleeding is typically self-limited or endo-
scopically treatable, although life-threatening venous
hemorrhage can occur from the splenic vein, portal vein,
or intra-abdominal varices. Serious venous bleeding may
not be as clinically dramatic as arterial hemorrhage, but
could prove more challenging to address because
angiographic options are limited. There are no structured
studies on management approaches to intracavitary
venous bleeding, but continuous infusion of octreotide
and urgent surgery to pack the cyst cavity is occasionally
lifesaving. In cases of massive intraprocedural bleeding,
endoscopic occlusion of the transmural tract with a
large-caliber balloon can provide sufficient tamponade to
permit adequate resuscitation and transport of the pa-
tient to the interventional radiology suite or operating
room (Video 5).
Perforation of the cyst or gastroduodenal wall com-
plicates approximately 5% of cases and may occur
intraprocedurally or in delayed fashion.28,29 Perforation
of the transmural tract or separation of the cyst from the
GI tract, when recognized during the procedure, can be
sealed with a fcSEMS, such as a through-the-scope
esophageal stent or LAMS. Free peritoneal gas after
drainage may be caused by carbon dioxide tracking be-
tween the GI tract and cyst, does not always signify
ongoing abdominal contamination, and should be
managed conservatively in stable patients with a reas-
suring abdominal examination. Even clinically relevant
perforations, depending on the amount of residual ne-
crosis within the cavity, can be managed nonoperatively
with nil per os and intravenous antibiotics.28,29 Among
patients with peritoneal signs or evidence of abdominal
sepsis who require surgical intervention, exposure of the
lesser sac and definitive management of the fluid
collection in real-time is not always necessary, particu-
larly if the cyst has been adequately drained and the
transmural defect is closed endoscopically.85 The
complexity of decision-making in these cases un-
derscores the importance of a strong interdisciplinary
working relationship.
Follow-up
There are no clear follow-up guidelines after endo-
scopic drainage of PFCs and practice patterns vary
widely between endoscopists. Patients who present for
an ambulatory drainage procedure are not routinely
admitted at our institution unless there is concern for a
complication. After uncomplicated endoscopic drainage
or debridement, oral intake can be resumed and oral
antibiotics are typically prescribed. Some endoscopists
Clinical Gastroenterology and Hepatology Vol. 16, No. 12
continue antibiotic therapy until the collection has fully
collapsed. However, I generally prescribe a 10- to 14-day
course even if the subsequent procedure will occur
several weeks later. A general approach to the timing of
repeat imaging and procedures is outlined in the
Supplementary Appendix.
Supplementary Material
Note: To access the supplementary material accom-
panying this article, visit the online version of Clinical
Gastroenterology and Hepatology at www.cghjournal.org,
and at https://doi.org/10.1016/j.cgh.2018.03.021.
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Reprint requests
Address requests for reprints to: B. Joseph Elmunzer, MD, Division of
Gastroenterology & Hepatology, Medical University of South Carolina, MSC
702, 114 Doughty Street, Suite 249, Charleston, South Carolina 29425. e-mail:
Elmunzer@musc.edu; fax: (843) 876-8574.
Conflicts of interest
The author discloses no conflicts.
1863.e1 B. Joseph Elmunzer
Supplementary Appendix
Transmural Drainage of Collections Before 4
Weeks After Acute Pancreatitis
Occasionally, endoscopic drainage can be performed
before the 4-week mark if the indication is strong, it is
considered the patient’s best option, and the collection
appears to have a mature wall on cross-sectional imaging
and endoscopic ultrasound. Although many experts have
performed successful endoscopic drainage in this early
phase, the potential for cyst wall perforation is higher
and should be considered in the risk-benefit discussion.
Ideally, percutaneous drainage can temporize a patient
well enough for several weeks to allow cyst wall matu-
ration and subsequent endoscopic or surgical
intervention.
Transpapillary Drainage of
Walled-Off Necrosis
Walled-off necrosis (WON) generally does not
respond to transpapillary stent placement alone because
the necrotic content is unlikely to drain through the stent
and prevents cyst collapse, although exceptions to this
rule have been reported. If circumstances are such that
an attempt at transpapillary drainage of a reasonably
small WON is deemed to be the best initial option, a more
extended course of antibiotics is worth considering, and
a clear plan for salvage percutaneous, endoscopic, or
surgical drainage should be in place.
Location of the Cyst-Gastrostomy
or Cyst-Duodenostomy
In principle, the location of the conduit before endo-
scopic necrosectomy (EN) should be thoughtful, allowing
the most mechanically advantageous access to the cavity
with a gastroscope, which is important for debridement.
However, the safest and most stable location should
typically be selected because mechanical disadvantage
can generally be overcome by abdominal pressure, pa-
tient position change, and in some cases the creation of a
second gateway.
Multiple Wires
Multiple wires must be advanced into the cyst in
parallel when the goal is transmural placement of several
plastic stents. This can be accomplished by wire cannu-
lation of the established tract alongside an existing wire
or stent, although this technique can be surprisingly
difficult in some cases and the second wire may dissect
between the gastrointestinal tract and cyst wall. Other
options include advancing a dedicated multiwire cath-
eter (Haber ramp), a 10F catheter stent pusher, or a
Clinical Gastroenterology and Hepatology Vol. 16, No. 12
wire-guided cytology brush (with brush removed) over
the first wire and subsequently introducing additional
wires into the cyst. The 10F catheter cystotome also has
a large enough lumen to accommodate a second wire
once the internal contents (needle knife and internal
catheter) are removed.1,2
Duodenoscope for Cyst-Gastrostomy
or Cyst-Duodenostomy
Some endoscopists still access the cyst with endo-
scopic ultrasound and then exchange for a duodenoscope
based on personal comfort, optics, and stability. How-
ever, this practice has fallen out of favor because of its
inefficiency, the risk of losing wire access during ex-
change, and the difficulty in pivoting back to endoscopic
ultrasound if necessary.
Additional Technical Considerations
During Necrosectomy
The process of debridement should be controlled and
methodical because vessels and viable pancreatic pa-
renchyma may be obscured within or adjacent to
necrotic tissue. The degree of force that can be used to
safely detach adherent necrosis is unclear, although
judgment must be used because excessive traction may
theoretically result in perforation of the cyst wall. Slow
and steady traction can occasionally allow retrieval of
very large pieces of necrosis rather than simply shearing
off smaller morsels (Supplementary Figure 1).
Occasionally, in the case of recalcitrant infection
caused by a complex cavity, an XP neonatal gastroscope
can be used to explore and debride small compartments
by irrigation, suctioning, and use of a pediatric forceps or
snare.
After EN, placement of transmural plastic stents does
not require a wire and fluoroscopic guidance (ie, can be
performed in a nonfluoroscopy capable suite). These
prostheses can be placed under endoscopic visualization
after back-loading the stent into the accessory channel of
the gastroscope (Videos 6 and 7).
Additional Considerations Pertaining to
Lumen-Apposing Metal Stents
First, the deployment process is not as straightfor-
ward as other stents, although it does become more
intuitive as experience is gained (Video 8). Maldeploy-
ment into the cavity, tract, or lumen can occur3–5 but may
have decreased since the recognition that the intra-
luminal flange does not necessarily need to be deployed
under endoscopic view but rather can be deployed into
the accessory channel and then expelled by cautious
scope withdrawal and catheter hub advancement.
Deployment into the cyst or tract can be salvaged by
December 2018
dilation of the tract over the wire using a balloon or
biliary fully covered metal stent to expose the lumen-
apposing metal stent (LAMS) and allow retrieval with a
rat-toothed forceps.4 Although the electrocautery-
enhanced deployment platform does not require ante-
cedent wire access, use of a wire does allow salvage in
the event of errant deployment (and allows exclusion of
blood in cyst as explained previously).
Second, even though LAMS provide a large lumen
through which spontaneous egress of necrotic content
from the cyst cavity can occur, stent failure by occlusion
or migration remains a problem. For example, we and
others have observed many cases of tract obstruction
despite LAMS placement because of occlusion of the stent
by necrotic debris or the cyst wall, or migration of the
prosthesis into the gastrointestinal tract.6 Some endo-
scopists place 1 or more double pigtail plastic stents
through the LAMS to prevent complete occlusion by
debris or the cyst wall,7 although the effectiveness of this
strategy remains unclear and we have seen complete oc-
clusion despite plastic stent placement (Supplementary
Figure 2).
Finally, LAMS may be associated with an increased
risk of adverse events, especially clinically important
bleeding, although this observation has been inconsis-
tent.3,8,9 Several recent reports have suggested a higher
incidence of LAMS-induced bleeding as a result of
erosion of the prosthesis into vascular structures
perhaps caused by more rapid cyst collapse and/or the
physical characteristics of the stent. Since it has been
reported that the likelihood of a bleeding event is related
to dwell time, some experts perform follow-up imaging
in a shorter interval than usual with the intention of
removing the LAMS as soon as possible.10 Other com-
plications that may be more common with LAMS are
buried stent and perforation,11 both potentially related
to the shorter length of the prosthesis.
Post-Procedural Imaging and Follow-up
In cases of transpapillary and/or transmural drainage
of pseudocyst, repeat cross-sectional imaging is often
performed 3–4 weeks later, ideally on the same day as a
follow-up procedure to remove or replace the stents. If
the collection has resolved and there is no suspicion or
evidence of an ongoing pancreatic leak, then the trans-
mural stents can be removed. If the collection remains,
then the transmural stents should be assessed for
patency and replaced if necessary, and an endoscopic
retrograde cholangiopancreatography should be consid-
ered if not already performed. The patency of plastic
stents cannot be reliably assessed in situ so they require
empiric exchange, but metallic stents can be assessed by
endoscopic exploration (neonatal gastroscope for fully
covered metal stents) or injection of contrast. Persistent
failure of a pseudocyst to resolve should prompt
Pancreatic Fluid Collections 1863.e2
evaluation for unrecognized cyst contents, such as ne-
crosis or blood, in addition to assessing pancreatic duct
integrity.
In the case of a clinically unwell inpatient with WON,
EN sessions are repeated every 2–3 days until improve-
ment in infectious parameters is achieved. Once the pa-
tient’s clinical status improves enough to permit discharge,
then EN sessions can be performed every 2–4 weeks in the
outpatient setting until the necrosis is completely debri-
ded, at which point a follow-up approach similar to
pseudocyst is adopted. Follow-up procedures for WON
generally do not require fluoroscopy unless an endoscopic
retrograde cholangiopancreatography is indicated.
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1863.e3 B. Joseph Elmunzer Clinical Gastroenterology and Hepatology Vol. 16, No. 12

Supplementary Figure 1. Large piece of necrosis removed

by slow and steady traction.

Supplementary Figure 2. Complete occlusion of a LAMS

(small arrows) by blood clot despite placement of a plastic
double pigtail stent (long arrow) through its lumen.