V. Raman Muthusamy, MD, FASGE, from the ASGE Standards of Practice committee writes about the new ASGE guideline, “The role of endoscopy in the diagnosis and treatment of inflammatory pancreatic fluid collections.”

The purpose of this guideline is to review the most recent classification of inflammatory pancreatic fluid collections, discuss when endoscopic intervention is appropriate, and to describe the latest endoscopic techniques for the treatment of these collections and their outcomes.

The previous guideline was published in 2005, and the classification and management approaches/options regarding these collections have changed significantly over the past decade.

This updated document provides guidance on distinguishing the different types of pancreatic fluid collections from each other. Furthermore, the appropriate indications for intervention and the proper timing of proposed interventions are discussed in detail. A description of the techniques and types of endoscopic drainage options for pseudocysts and walled off necrosis, many of them recently developed, is also provided. Finally, the the frrequency and nature of adverse events associated with these methods, as well as the their clinical outcomes, are presented. Endoscopic treatment of inflammatory fluid collections has improved greatly over the last decade with the development of transmural techniques, usually performed entirely via endoscopic ultrasound, that provide drainage and the ability to perform necrosectomy. The creation of multiple drainage sites appears to be associated with improved outcomes in walled off necrosis. Recent technological advances, including the development of lumen-apposing metal stents, have dramatically simplified the transmural drainage technique and have facilitated the performance of necrosectomy. The role of transpapillary drainage via ERCP has greatly diminished, and it is typically reserved for very select cases involving partial pancreatic ductal disruption or duct obstruction from strictures or stones. Recent data suggest combined transpapillary and transmural drainage is no better than transmural drainage alone.

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