Peripancreatic Fluid Collections

Educational Objectives

The goal of this program is to improve the diagnosis and management of peripancreatic fluid collections. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose acute pancreatitis.
2. Evaluate the surgical management of peripancreatic fluid collections, including necrosectomy and debridement.

Summary

Acute pancreatitis: characterized by an acute inflammation of the pancreas; histology shows acinar cell destruction; diagnosed upon presentation with 2 of 3 criteria, ie, severe abdominal pain, significantly elevated levels of pancreatic enzymes (amylase or lipase, 3 times the normal limit), characteristic abnormalities detected on abdominal imaging; the American College of Radiology published guidelines for imaging patients with suspected acute pancreatitis; ultrasonography (USG) is preferred for initial imaging, especially for first-time presentations; the appropriateness of other imaging modalities (eg, computed tomography [CT], magnetic resonance cholangiopancreatography [CP]) is questioned

Severity: several severity scores are used to assess risk for complications and guide treatment decisions, eg, the revised Atlanta classification, Ranson criteria

Role of endoscopy: guidelines from the American Society of Gastroenterology suggest endoscopic retrograde CP (ERCP) or laparoscopic cholecystectomy (LC) for patients at high risk for choledocholithiosis or with positive intraoperative cholangiography; the risk for development of gallstones in patients with pancreatitis is identified based on, eg, elevated bilirubin (>4 mg/dL), the presence of common bile duct stone on USG; decision for ERCP is based on the patient’s clinical presentation

Laparoscopic cholecystectomy: evidence suggests that early LC ≤72 hr is safe in patients with biliary pancreatitis and does not increase the risk for intraoperative or postoperative complications or the need for conversion to open surgery

Peripancreatic fluid collections: there are 6 types of choledochal cysts; the clinician should consider imaging in patients with persistent abdominal pain, nausea, and/or weight loss, even in cases of mild initial presentation; magnetic resonance imaging (MRI) may show postpancreatic fluid collections; alternatively, CT of the abdomen and pelvis (with or without contrast) and USG may be advised; pseudocyst — a fluid collection that occurs after 5 wk; has a thick rim and differs from pancreatic necrosis, pancreatic abscess, peripancreatic fluid collection, and walled-off pancreatic necrosis

Sterile necrotizing pancreatitis: intervention may be required if persistent symptoms, eg, pain or obstruction, are present, even without signs of infection; indications include ongoing gastric outlet or biliary obstruction because of mass effect, persistent symptoms in patients with walled-off necrosis, and disconnected duct syndrome causing persistent pain or abdominal pain without necrosis; interventions are typically delayed until the necrotic tissue has walled off to minimize complications; surgical intervention to address both the gallbladder and the necrotic cyst in a single procedure may be advised; an endoscopic approach is used for frail patients; certain factors (eg, patient condition, surgeon expertise, the specific characteristics of the necrotic cyst) influence the choice between surgery and endoscopic procedure

Evidence: Khreiss et al (2015) — compared minimally invasive surgery (MIS) with endoscopic intervention for treating pancreatic necrosis; the study found that, while endoscopic interventions may have lower individual hospital stays, the cumulative hospitalizations required for multiple procedures often offsets this advantage; the cost difference between the 2 approaches was not significant; impact on patient quality of life should be considered, as repeated endoscopic procedures may lead to increased discomfort, pain, and dependence on medications; step-up approach — involves placing a drain in the lesser sac and gradually upsizing it over time, allowing access to the retroperitoneum and subsequent endoscopic necrosectomy; van Santvoort et al (2010) — compared the step-up approach vs open necrosectomy and found significant advantages with the step-up approach, including lower rates of multiple organ failure, incisional hernia, and neurologic deficits

Disconnected duct syndrome: patients typically present with pancreatic fluid collection and undergo endoscopic intervention, including stent placement; some may experience recurrence of symptoms, with MRI revealing disconnected duct syndrome; the surgeon may opt for a conservative approach, avoiding immediate surgery and instead focusing on endoscopic management to assess the extent of the duct disruption; the goal is to determine whether a pancreaticoduodenectomy (Whipple procedure) would be necessary or if a less invasive approach, eg, pancreaticogastrostomy, may be considered; the dissection process is often complex and prone to bleeding because of the presence of numerous veins, including the pancreatic vein, which is frequently thrombosed; to mitigate the risk for postoperative leakage, the surgeon often places a short pancreatic duct stent in the pancreatic head prior to resection; this stent helps to maintain ductal integrity and reduce the likelihood of leakage

Partial vs complete duct disruption: for partial disruptions, endoscopic placement of a pancreatic duct stent may often effectively repair the damage and prevent recurrent fluid collections; however, complete disruptions, particularly those involving the tail of the pancreas, are more challenging to manage; endoscopic interventions may provide temporary relief, but ultimately, a distal pancreatectomy and splenectomy are often required to address the persistent leakage and prevent complications; distal pancreatectomy is technically challenging, particularly in cases with a thrombosed splenic vein and varices; while splenic preservation may be desirable, it is often not feasible because of the increased risk of bleeding and other complications; timely and appropriate care may be hindered by health care disparities in certain regions; improved access to specialized care is needed, especially for patients in rural areas, to ensure optimal outcomes

Readings

Ackermann TG, Cashin PA, Alwan M, et al. The role of laparoscopic cholecystectomy after severe and/or necrotic pancreatitis in the setting of modern minimally invasive management of pancreatic necrosis. Pancreas. 2020;49(7):935-940. doi:10.1097/MPA.0000000000001601; Bhakta D, de Latour R, Khanna L. Management of pancreatic fluid collections. Transl Gastroenterol Hepatol. 2022;7:17. Published 2022 Apr 25. doi:10.21037/tgh-2020-06; Khreiss M, Zenati M, Clifford A, et al. Cyst gastrostomy and necrosectomy for the management of sterile walled-off pancreatic necrosis: A comparison of minimally invasive surgical and endoscopic outcomes at a high-volume pancreatic center. J Gastrointest Surg. 2015;19(8):1441-1448. doi:10.1007/s11605-015-2864-6; Szatmary P, Grammatikopoulos T, Cai W, et al. Acute pancreatitis: Diagnosis and treatment. Drugs. 2022;82(12):1251-1276. doi:10.1007/s40265-022-01766-4; van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010;362(16):1491-1502. doi:10.1056/NEJMoa0908821; Umapathy C, Gajendran M, Mann R, et al. Pancreatic fluid collections: Clinical manifestations, diagnostic evaluation and management. Dis Mon. 2020;66(11):100986. doi:10.1016/j.disamonth.2020.100986.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Khreiss was recorded at Phoenix Surgical Society Symposium 2024, held February 8-10, 2024, in Scottsdale, AZ, and presented by Phoenix Surgical Society. For information on upcoming CME activities from this presenter, please visit phoenixsurgicalsociety.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

GS720302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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