Endoscopic Drainage of Pancreatic Fluid Collections

  • Natalie Danielle Cosgrove
  • Pushpak Taunk
  • Haroon Shahid
  • Ali Ahmed SiddiquiEmail author


Pancreatic fluid collections are fluid-filled cavities that develop and evolve in the setting of acute and chronic pancreatitis as well as pancreatic necrosis. While most fluid collections resolve spontaneously, many will mature over several weeks into organized collections with a radiologically visualized non-epithelial lined capsule. These collections are referred to as pancreatic pseudocysts or walled-off necrosis, depending on their internal components. Pseudocysts contain primarily liquid contents while walled-off necrosis contains variable amounts of both solid and liquid debris. Symptomatic and infected collections are indications for intervention. The primary management was previously surgical, but has become less invasive over the past several decades with endoscopic drainage and debridement, now the favored approach in most centers. This chapter discusses how and when endoscopic drainage should be performed and the role of ERCP and EUS in performing these procedures.


Pancreatic fluid collections Acute peripancreatic fluid collections Acute necrotic collections Pseudocysts Walled-off necrosis Transmural drainage Transpapillary drainage Pancreatic ductal disruption Disconnected pancreatic duct Cystenterostomy Cystogastrostomy Cystduodenostomy Endoscopic transmural necrosectomy Necrosectomy Multiple transluminal gateway technique Single transluminal gateway technique Single transluminal gateway transcystic multiple drainage technique Videoscopic assisted retroperitoneal debridement Sinus tract endoscopy Percutaneous catheter drainage 

Supplementary material

Video 14.1

The accompanying video demonstrates Dr. Adler performing an endoscopic transluminal necrosectomy using a lumen-apposing stent (WMV 59561 kb).


  1. 1.
    Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102–11.CrossRefPubMedGoogle Scholar
  2. 2.
    Takahashi N, Papachristou GI, Schmit GD, Chahal P, LeRoy AJ, Sarr MG, et al. CT findings of walled-off pancreatic necrosis (WOPN): differentiation from pseudocyst and prediction of outcome after endoscopic therapy. Eur Radiol. 2008;18(11):2522–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Trikudanathan G, Attam R, Arain MA, Mallery S, Freeman ML. Endoscopic interventions for necrotizing pancreatitis. Am J Gastroenterol. 2014;109(7):969–81. quiz 82.CrossRefPubMedGoogle Scholar
  4. 4.
    Working Group IAPAPAAPG. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13(4 Suppl 2):e1–15.Google Scholar
  5. 5.
    Braden B, Dietrich CF. Endoscopic ultrasonography-guided endoscopic treatment of pancreatic pseudocysts and walled-off necrosis: new technical developments. World J Gastroenterol. 2014;20(43):16191–6.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Jacobson BC, Baron TH, Adler DG, Davila RE, Egan J, Hirota WK, et al. ASGE guideline: the role of endoscopy in the diagnosis and the management of cystic lesions and inflammatory fluid collections of the pancreas. Gastrointest Endosc. 2005;61(3):363–70.CrossRefPubMedGoogle Scholar
  7. 7.
    Cheruvu CV, Clarke MG, Prentice M, Eyre-Brook IA. Conservative treatment as an option in the management of pancreatic pseudocyst. Ann R Coll Surg Engl. 2003;85(5):313–6.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Barthet M, Bugallo M, Moreira LS, Bastid C, Sastre B, Sahel J. Management of cysts and pseudocysts complicating chronic pancreatitis. A retrospective study of 143 patients. Gastroenterol Clin Biol. 1993;17(4):270–6.PubMedGoogle Scholar
  9. 9.
    Cui ML, Kim KH, Kim HG, Han J, Kim H, Cho KB, et al. Incidence, risk factors and clinical course of pancreatic fluid collections in acute pancreatitis. Dig Dis Sci. 2014;59(5):1055–62.CrossRefPubMedGoogle Scholar
  10. 10.
    Kim KO, Kim TN. Acute pancreatic pseudocyst: incidence, risk factors, and clinical outcomes. Pancreas. 2012;41(4):577–81.CrossRefPubMedGoogle Scholar
  11. 11.
    van Santvoort HC, Bakker OJ, Bollen TL, Besselink MG, Ahmed Ali U, Schrijver AM, et al. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology. 2011;141(4):1254–63.CrossRefPubMedGoogle Scholar
  12. 12.
    Gardner TB, Coelho-Prabhu N, Gordon SR, Gelrud A, Maple JT, Papachristou GI, et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc. 2011;73(4):718–26.CrossRefPubMedGoogle Scholar
  13. 13.
    Baron TH, Harewood GC, Morgan DE, Yates MR. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts. Gastrointest Endosc. 2002;56(1):7–17.CrossRefPubMedGoogle Scholar
  14. 14.
    Freeman ML, Werner J, van Santvoort HC, Baron TH, Besselink MG, Windsor JA, et al. Interventions for necrotizing pancreatitis: summary of a multidisciplinary consensus conference. Pancreas. 2012;41(8):1176–94.CrossRefPubMedGoogle Scholar
  15. 15.
    Gardner TB. Endoscopic management of necrotizing pancreatitis. Gastrointest Endosc. 2012;76(6):1214–23.CrossRefPubMedGoogle Scholar
  16. 16.
    Chauhan SS, Forsmark CE. Evidence-based treatment of pancreatic pseudocysts. Gastroenterology. 2013;145(3):511–3.CrossRefPubMedGoogle Scholar
  17. 17.
    Varadarajulu S, Bang JY, Sutton BS, Trevino JM, Christein JD, Wilcox CM. Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial. Gastroenterology. 2013;145(3):583–90. e1.CrossRefPubMedGoogle Scholar
  18. 18.
    Varadarajulu S, Bang JY, Phadnis MA, Christein JD, Wilcox CM. Endoscopic transmural drainage of peripancreatic fluid collections: outcomes and predictors of treatment success in 211 consecutive patients. J Gastrointest Surg. 2011;15(11):2080–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Akshintala VS, Saxena P, Zaheer A, Rana U, Hutfless SM, Lennon AM, et al. A comparative evaluation of outcomes of endoscopic versus percutaneous drainage for symptomatic pancreatic pseudocysts. Gastrointest Endosc. 2014;79(6):921–8. quiz 83 e2, 83 e5.CrossRefPubMedGoogle Scholar
  20. 20.
    Hariri M, Slivka A, Carr-Locke DL, Banks PA. Pseudocyst drainage predisposes to infection when pancreatic necrosis is unrecognized. Am J Gastroenterol. 1994;89(10):1781–4.PubMedGoogle Scholar
  21. 21.
    Monkemuller KE, Baron TH, Morgan DE. Transmural drainage of pancreatic fluid collections without electrocautery using the Seldinger technique. Gastrointest Endosc. 1998;48(2):195–200.CrossRefPubMedGoogle Scholar
  22. 22.
    Yusuf TE, Baron TH. Endoscopic transmural drainage of pancreatic pseudocysts: results of a national and an international survey of ASGE members. Gastrointest Endosc. 2006;63(2):223–7.CrossRefPubMedGoogle Scholar
  23. 23.
    Committee ASoP, Khashab MA, Chithadi KV, Acosta RD, Bruining DH, Chandrasekhara V, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc. 2015;81(1):81–9.CrossRefGoogle Scholar
  24. 24.
    Arvanitakis M, Delhaye M, Bali MA, Matos C, De Maertelaer V, Le Moine O, et al. Pancreatic-fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc. 2007;65(4):609–19.CrossRefPubMedGoogle Scholar
  25. 25.
    Holt BA, Varadarajulu S. EUS-guided drainage: beware of the pancreatic fluid collection (with videos). Gastrointest Endosc. 2014;80(6):1199–202.CrossRefPubMedGoogle Scholar
  26. 26.
    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(6):1107–19.CrossRefPubMedGoogle Scholar
  27. 27.
    Panamonta N, Ngamruengphong S, Kijsirichareanchai K, Nugent K, Rakvit A. Endoscopic ultrasound-guided versus conventional transmural techniques have comparable treatment outcomes in draining pancreatic pseudocysts. Eur J Gastroenterol Hepatol. 2012;24(12):1355–62.CrossRefPubMedGoogle Scholar
  28. 28.
    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(6):1102–11.CrossRefPubMedGoogle Scholar
  29. 29.
    Baron TH. Drainage of pancreatic fluid collections: is EUS really necessary? Gastrointest Endosc. 2007;66(6):1123–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Singhal S, Rotman SR, Gaidhane M, Kahaleh M. Pancreatic fluid collection drainage by endoscopic ultrasound: an update. Clin Endosc. 2013;46(5):506–14.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Adler DG, Baron TH, Davila RE, Egan J, Hirota WK, Leighton JA, et al. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas. Gastrointest Endosc. 2005;62(1):1–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Barthet M, Lamblin G, Gasmi M, Vitton V, Desjeux A, Grimaud JC. Clinical usefulness of a treatment algorithm for pancreatic pseudocysts. Gastrointest Endosc. 2008;67(2):245–52.CrossRefPubMedGoogle Scholar
  33. 33.
    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(6):1408–12.CrossRefPubMedGoogle Scholar
  34. 34.
    Barthet M, Sahel J, Bodiou-Bertei C, Bernard JP. Endoscopic transpapillary drainage of pancreatic pseudocysts. Gastrointest Endosc. 1995;42(3):208–13.CrossRefPubMedGoogle Scholar
  35. 35.
    Bakker OJ, van Baal MC, van Santvoort HC, Besselink MG, Poley JW, Heisterkamp J, et al. Endoscopic transpapillary stenting or conservative treatment for pancreatic fistulas in necrotizing pancreatitis: multicenter series and literature review. Ann Surg. 2011;253(5):961–7.CrossRefPubMedGoogle Scholar
  36. 36.
    Telford JJ, Farrell JJ, Saltzman JR, Shields SJ, Banks PA, Lichtenstein DR, et al. Pancreatic stent placement for duct disruption. Gastrointest Endosc. 2002;56(1):18–24.CrossRefPubMedGoogle Scholar
  37. 37.
    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(4):568–75.CrossRefPubMedGoogle Scholar
  38. 38.
    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(3):526–31.CrossRefPubMedGoogle Scholar
  39. 39.
    Hookey LC, Debroux S, Delhaye M, Arvanitakis M, Le Moine O, Deviere J. Endoscopic drainage of pancreatic-fluid collections in 116 patients: a comparison of etiologies, drainage techniques, and outcomes. Gastrointest Endosc. 2006;63(4):635–43.CrossRefPubMedGoogle Scholar
  40. 40.
    Irani S, Gluck M, Ross A, Gan SI, Crane R, Brandabur JJ, et al. Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video). Gastrointest Endosc. 2012;76(3):586–93. e1–3.CrossRefPubMedGoogle Scholar
  41. 41.
    Kozarek RA. Pancreatic stents can induce ductal changes consistent with chronic pancreatitis. Gastrointest Endosc. 1990;36(2):93–5.CrossRefPubMedGoogle Scholar
  42. 42.
    D'Egidio A, Schein M. Surgical strategies in the treatment of pancreatic necrosis and infection. Br J Surg. 1991;78(2):133–7.CrossRefPubMedGoogle Scholar
  43. 43.
    Bakker OJ, van Santvoort HC, van Brunschot S, Geskus RB, Besselink MG, Bollen TL, et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA. 2012;307(10):1053–61.CrossRefPubMedGoogle Scholar
  44. 44.
    van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362(16):1491–502.CrossRefPubMedGoogle Scholar
  45. 45.
    Tong Z, Li W, Yu W, Geng Y, Ke L, Nie Y, et al. Percutaneous catheter drainage for infective pancreatic necrosis: is it always the first choice for all patients? Pancreas. 2012;41(2):302–5.CrossRefPubMedGoogle Scholar
  46. 46.
    van Baal MC, van Santvoort HC, Bollen TL, Bakker OJ, Besselink MG, Gooszen HG, et al. Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg. 2011;98(1):18–27.CrossRefPubMedGoogle Scholar
  47. 47.
    Kumar N, Conwell DL, Thompson CC. Direct endoscopic necrosectomy versus step-up approach for walled-off pancreatic necrosis: comparison of clinical outcome and health care utilization. Pancreas. 2014;43(8):1334–9.CrossRefPubMedGoogle Scholar
  48. 48.
    van Brunschot S, van Grinsven J, Voermans RP, Bakker OJ, Besselink MG, Boermeester MA, et al. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol. 2013;13:161.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Seewald S, Ang TL, Kida M, Teng KY, Soehendra N, Group EUSW. EUS 2008 Working Group document: evaluation of EUS-guided drainage of pancreatic-fluid collections (with video). Gastrointest Endosc. 2009;69(2 Suppl):S13–21.CrossRefPubMedGoogle Scholar
  50. 50.
    Baron TH. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis. Gastrointest Endosc Clin N Am. 2003;13(4):743–64.CrossRefPubMedGoogle Scholar
  51. 51.
    Gardner TB, Chahal P, Papachristou GI, Vege SS, Petersen BT, Gostout CJ, et al. A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis. Gastrointest Endosc. 2009;69(6):1085–94.CrossRefPubMedGoogle Scholar
  52. 52.
    Siddiqui AA, Dewitt JM, Strongin A, Singh H, Jordan S, Loren DE, et al. Outcomes of EUS-guided drainage of debris-containing pancreatic pseudocysts by using combined endoprosthesis and a nasocystic drain. Gastrointest Endosc. 2013;78(4):589–95.CrossRefPubMedGoogle Scholar
  53. 53.
    Baron TH, Thaggard WG, Morgan DE, Stanley RJ. Endoscopic therapy for organized pancreatic necrosis. Gastroenterology. 1996;111(3):755–64.CrossRefPubMedGoogle Scholar
  54. 54.
    Baron TH, Morgan DE. Endoscopic transgastric irrigation tube placement via PEG for debridement of organized pancreatic necrosis. Gastrointest Endosc. 1999;50(4):574–7.CrossRefPubMedGoogle Scholar
  55. 55.
    Varadarajulu S, Phadnis MA, Christein JD, Wilcox CM. Multiple transluminal gateway technique for EUS-guided drainage of symptomatic walled-off pancreatic necrosis. Gastrointest Endosc. 2011;74(1):74–80.CrossRefPubMedGoogle Scholar
  56. 56.
    Mukai S, Itoi T, Sofuni A, Itokawa F, Kurihara T, Tsuchiya T, et al. Expanding endoscopic interventions for pancreatic pseudocyst and walled-off necrosis. J Gastroenterol. 2014.Google Scholar
  57. 57.
    Seifert H, Wehrmann T, Schmitt T, Zeuzem S, Caspary WF. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet. 2000;356(9230):653–5.CrossRefPubMedGoogle Scholar
  58. 58.
    van Brunschot S, Fockens P, Bakker OJ, Besselink MG, Voermans RP, Poley JW, et al. Endoscopic transluminal necrosectomy in necrotising pancreatitis: a systematic review. Surg Endosc. 2014;28(5):1425–38.CrossRefPubMedGoogle Scholar
  59. 59.
    Baron TH, Kozarek RA. Endotherapy for organized pancreatic necrosis: perspectives after 20 years. Clin Gastroenterol Hepatol. 2012;10(11):1202–7.CrossRefPubMedGoogle Scholar
  60. 60.
    Seewald S, Ang TL, Teng KC, Soehendra N. EUS-guided drainage of pancreatic pseudocysts, abscesses and infected necrosis. Dig Endosc. 2009;21 Suppl 1:S61–5.CrossRefPubMedGoogle Scholar
  61. 61.
    Papachristou GI, Takahashi N, Chahal P, Sarr MG, Baron TH. Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg. 2007;245(6):943–51.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Gluck M, Ross A, Irani S, Lin O, Hauptmann E, Siegal J, et al. Endoscopic and percutaneous drainage of symptomatic walled-off pancreatic necrosis reduces hospital stay and radiographic resources. Clin Gastroenterol Hepatol. 2010;8(12):1083–8.CrossRefPubMedGoogle Scholar
  63. 63.
    Gluck M, Ross A, Irani S, Lin O, Gan SI, Fotoohi M, et al. Dual modality drainage for symptomatic walled-off pancreatic necrosis reduces length of hospitalization, radiological procedures, and number of endoscopies compared to standard percutaneous drainage. J Gastrointest Surg. 2012;16(2):248–56. discussion 56-7.CrossRefPubMedGoogle Scholar
  64. 64.
    Ross AS, Irani S, Gan SI, Rocha F, Siegal J, Fotoohi M, et al. Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes. Gastrointest Endosc. 2014;79(6):929–35.CrossRefPubMedGoogle Scholar
  65. 65.
    Navarrete C, Castillo C, Caracci M, Vargas P, Gobelet J, Robles I. Wide percutaneous access to pancreatic necrosis with self-expandable stent: new application (with video). Gastrointest Endosc. 2011;73(3):609–10.CrossRefPubMedGoogle Scholar
  66. 66.
    Committee AT, Desilets DJ, Banerjee S, Barth BA, Bhat YM, Gottlieb KT, et al. New devices and techniques for management of pancreatic fluid collections. Gastrointest Endosc. 2013;77(6):835–8.CrossRefGoogle Scholar
  67. 67.
    Voermans RP, Ponchon T, Schumacher B, Fumex F, Bergman JJ, Larghi A, et al. Forward-viewing versus oblique-viewing echoendoscopes in transluminal drainage of pancreatic fluid collections: a multicenter, randomized, controlled trial. Gastrointest Endosc. 2011;74(6):1285–93.CrossRefPubMedGoogle Scholar
  68. 68.
    Talreja JP, Shami VM, Ku J, Morris TD, Ellen K, Kahaleh M. Transenteric drainage of pancreatic-fluid collections with fully covered self-expanding metallic stents (with video). Gastrointest Endosc. 2008;68(6):1199–203.CrossRefPubMedGoogle Scholar
  69. 69.
    Antillon MR, Bechtold ML, Bartalos CR, Marshall JB. Transgastric endoscopic necrosectomy with temporary metallic esophageal stent placement for the treatment of infected pancreatic necrosis (with video). Gastrointest Endosc. 2009;69(1):178–80.CrossRefPubMedGoogle Scholar
  70. 70.
    Sarkaria S, Sethi A, Rondon C, Lieberman M, Srinivasan I, Weaver K, et al. Pancreatic necrosectomy using covered esophageal stents: a novel approach. J Clin Gastroenterol. 2014;48(2):145–52.CrossRefPubMedGoogle Scholar
  71. 71.
    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;7(4):486–98.CrossRefGoogle Scholar
  72. 72.
    Ahlawat SK, Charabaty-Pishvaian A, Jackson PG, Haddad NG. Single-step EUS-guided pancreatic pseudocyst drainage using a large channel linear array echoendoscope and cystotome: results in 11 patients. JOP. 2006;7(6):616–24.PubMedGoogle Scholar
  73. 73.
    Kruger M, Schneider AS, Manns MP, Meier PN. Endoscopic management of pancreatic pseudocysts or abscesses after an EUS-guided 1-step procedure for initial access. Gastrointest Endosc. 2006;63(3):409–16.CrossRefPubMedGoogle Scholar
  74. 74.
    Siddiqui AA, Easler J, Strongin A, Slivka A, Kowalski TE, Muddana V, et al. Hydrogen peroxide-assisted endoscopic necrosectomy for walled-off pancreatic necrosis: a dual center pilot experience. Dig Dis Sci. 2014;59(3):687–90.CrossRefPubMedGoogle Scholar
  75. 75.
    Wallstabe I, Tiedemann A, Schiefke I. Endoscopic vacuum-assisted therapy of an infected pancreatic pseudocyst. Endoscopy. 2011;43 Suppl 2 UCTN:E312-3.Google Scholar
  76. 76.
    Aso A, Igarashi H, Matsui N, Ihara E, Takaoka T, Osoegawa T, et al. Large area of walled-off pancreatic necrosis successfully treated by endoscopic necrosectomy using a grasping-type scissors forceps. Dig Endosc. 2014;26(3):474–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Natalie Danielle Cosgrove
    • 1
  • Pushpak Taunk
    • 2
  • Haroon Shahid
    • 3
  • Ali Ahmed Siddiqui
    • 4
    Email author
  1. 1.Thomas Jefferson UniversityPhiladelphiaUSA
  2. 2.University of South FloridaTampaUSA
  3. 3.Thomas Jefferson University HospitalPhiladelphiaUSA
  4. 4.Department of GastroenterologyThomas Jefferson University HospitalPhiladelphiaUSA

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