Endoscopic Ultrasound-guided Procedures for Pancreatic Fluid Collections

<jats:p>Pancreatic fluid collections (PFC), mostly referring to pseudocyst and walled-off necrosis (WON), arise after acute, chronic, and post-surgical pancreatic disease. Management has shifted over the past fifteen years from open surgery to EUS-guided transmural drainage. The PANTER, TENSION, and ExTENSION trials have empowered the step-up approach as the standard of care. More exactly, endoscopic step-up is not superior to surgical step-up on major outcomes but is associated with fewer pancreaticocutaneous fistulae and fewer late reinterventions. Lumen-apposing metal stents (LAMS) have contributed to a simplified transmural access and have enabled the opportunity of through-the-stent necrosectomy. However, a randomized trial found LAMS non-superior to double-pigtail plastic stents for WON on number of procedures to clinical success, and a nationwide Japanese database of 5885 patients reported higher bleeding risk with LAMS in pseudocyst drainage, making indications even more challenging. This chapter is written for gastroenterology trainees and general endoscopists setting up a PFC drainage programme. It tackles EUS-guided drainage within a multidisciplinary algorithm that includes percutaneous and surgical routes, addresses imaging-driven stent removal, and covers disconnected pancreatic duct syndrome as the main driver of recurrence after WON resolution. Recommendations follow the ESGE 2018 multidisciplinary guideline and incorporate recent meta-analytic and real-world evidence. Long-term indwelling double-pigtail plastic stents are presented as the accepted strategy for collections complicated by disconnected pancreatic duct syndrome, with cohorts followed beyond five years. Direct endoscopic necrosectomy technique, optimal LAMS dwell time of three to six weeks, and cost-effectiveness of LAMS versus plastic stents across reimbursement scenarios are also discussed.</jats:p>