Management of Pancreaticobiliary Disease: Pseudocyst

Endoscopic drainage of pancreatic pseudocysts has become the standard management approach for acute and chronic noninfected pancreatic collections. There are several techniques of performing a pancreatic cyst-gastrostomy including transpapillary, transgastric, and trans-duodenal methods. The technique is most easily performed on larger collections abutting the stomach with bleeding, infection, and perforation being potential complications. Endoscopic ultrasound extends the applicability to smaller pseudocyst which would otherwise be inaccessible endoscopically. Pancreatic necrosectomy via an endoscopic approach is an alternative to traditional operative drainage. Benefits of this nonoperative approach include decreased morbidity and decreased rates of fistula and hernia occurrence. The “step-up” approach to laparoscopic or operative debridement is a potential necessary backup. Endoscopic ultrasound can similarly extend indications and help avoid bleeding complications. Use of newer lumen-apposing metallic stents (LAMS) facilitates initial drainage and subsequent debridement procedures. The risk of bleeding and stent migration limits their longer-term use.