Combining transpapillary pancreatic duct stenting with endoscopic transmural drainage for pancreatic fluid collections: two heads are better than one!

摘要

Over the last two decades, there has been considerable advancement in the experience and instruments available for endoscopic drainage of pancreatic fluid collections (PFC), which can be done by either through the gastrointestinal wall by creating a cystogas-trostomy or a cystoduodenostomy (transmural drainage), or through the papilla (transpapillary drainage). Transmural drainage was originally performed by blind puncture at the site of maximum bulge on the gastric or duodenal wall followed by dilatation of the punctured tract and insertion of single or multiple stents. Bleeding and perforation were significant complications. However, the evolution of endoscopic ultrasound (EUS) has improved the safety profile of endoscopic transmural drainage. It has also extended the indications to include pancreatic abscess, organized liquefied necrosis, and non-bulging PFC. The presence of necrotic debris in the PFC necessitates a more aggressive approach that involves irrigation using a nasocystic catheter or a direct endoscopic necrosectomy.