EUS in managing Pancreatic Fluid Collections

Pancreatic fluid collections (PFC) include Pseudocyst & Walled off Necrosis (WON), differentiated by presence of solid debris within well-defined granulation tissue wall. Symptomatic PFC requires drainage which can be achieved using endoscopic, surgical or radiological interventions. The last two methods are being less preferred due to invasive nature, morbidity, prolonged stay, and cost. Endoscopic method is preferred for drainage of PFC located within 1 cm of the GI wall. However, pure endoscopic drainage without real time US imaging is fading out due to its blind approach (risk of puncturing interposing vessels) and inability to drain non-bulging PFC. Advantage of EUS guided PFC drainage include visualization of entire PFC, select thinnest point of entry even in non-bulging collections, with Doppler helping to avoid vessel. EUS guided puncture of PFC is done using either 19 G needle or cystotome. In first approach, after puncture guidewire is coiled inside PFC. Cysto-enteric fistula (CEF) is created using over-the-wire 6Fr cystotome, bougie or small caliber balloon. Further dilation with large caliber balloon and placement of >1 short 7-10 Fr plastic double pigtail stents drains PFC content into GI lumen. In second method, cystotome directly burns the wall of PFC to create CEF. For necrosectomy, CEF is dilated later with large caliber balloon followed by passage of endoscope inside PFC to remove debris. Recently, EUS guided placement of short wide caliber FCSEMS in PFC has eased the drainage procedure, including necrosectomy.