Digestive Disease Interventions 2023; 07(03): 145-151
DOI: 10.1055/s-0042-1745721
Review Article

Endoscopy in the Management of Complications of Acute Pancreatitis

Nicole Patel
2   Albany Medical College, Albany, New York
Ishani Shah
1   Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
3   Center for Interventional Gastroenterology at UT Health (iGUT), University of Texas Health Science Center at Houston, Houston, Texas
Mandeep S. Sawhney
1   Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts
› Author Affiliations


Acute pancreatitis (AP) is an acute necroinflammatory condition of the pancreas and one of the most common gastrointestinal conditions requiring hospitalization. Over the past decade, treatment of such AP-related complications has been majorly focused on incorporating a multidisciplinary approach involving distinct endoscopic, radiologic, and surgical interventions. Our review focuses on the role of endoscopic interventions in the management of local complications associated with AP, such as pancreatic fluid collections, walled-off necrosis, and pancreatic duct disruption.


None of the authors have any relevant financial disclosures to this manuscript.

Publication History

Received: 08 March 2021

Accepted: 03 February 2022

Article published online:
02 June 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

  • References

  • 1 Xiao AY, Tan ML, Wu LM. et al. Global incidence and mortality of pancreatic diseases: a systematic review, meta-analysis, and meta-regression of population-based cohort studies. Lancet Gastroenterol Hepatol 2016; 1 (01) 45-55
  • 2 Boxhoorn L, Voermans RP, Bouwense SA. et al. Acute pancreatitis. Lancet 2020; 396 (10252): 726-734
  • 3 Banks PA, Freeman ML. Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006; 101 (10) 2379-2400
  • 4 Leppäniemi A, Tolonen M, Tarasconi A. et al. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg 2019; 14: 27
  • 5 van Santvoort HC, Bakker OJ, Bollen TL. et al; Dutch Pancreatitis Study Group. A conservative and minimally invasive approach to necrotizing pancreatitis improves outcome. Gastroenterology 2011; 141 (04) 1254-1263
  • 6 Banks PA, Bollen TL, Dervenis C. et al; Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis–2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62 (01) 102-111
  • 7 Larvin M, McMahon MJ. APACHE-II score for assessment and monitoring of acute pancreatitis. Lancet 1989; 2 (8656): 201-205
  • 8 Basit H, Ruan GJ, Mukherjee S. Ranson Criteria. Treasure Island, FL: StatPearls Publishing; 2021. PMID: 29493970
  • 9 Alhajeri A, Erwin S. Acute pancreatitis: value and impact of CT severity index. Abdom Imaging 2008; 33 (01) 18-20
  • 10 Alberti P, Pando E, Mata R. et al. Evaluation of the modified computed tomography severity index (MCTSI) and computed tomography severity index (CTSI) in predicting severity and clinical outcomes in acute pancreatitis. J Dig Dis 2021; 22 (01) 41-48
  • 11 Hagjer S, Kumar N. Evaluation of the BISAP scoring system in prognostication of acute pancreatitis - a prospective observational study. Int J Surg 2018; 54 (Pt A): 76-81
  • 12 Tan YHA, Rafi S, Tyebally Fang M. et al. Validation of the modified Ranson versus Glasgow score for pancreatitis in a Singaporean population. ANZ J Surg 2017; 87 (09) 700-703
  • 13 Siriwardena AK, Jegatheeswaran S, Mason JM. et al. PROCalcitonin-based algorithm for antibiotic use in Acute Pancreatitis (PROCAP): study protocol for a randomised controlled trial. Trials 2019; 20 (01) 463
  • 14 Papachristou GI, Muddana V, Yadav D. et al. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol 2010; 105 (02) 435-441 , quiz 442
  • 15 Zhou H, Mei X, He X, Lan T, Guo S. Severity stratification and prognostic prediction of patients with acute pancreatitis at early phase: a retrospective study. Medicine (Baltimore) 2019; 98 (16) e15275
  • 16 Harshit Kumar A, Singh Griwan M. A comparison of APACHE II, BISAP, Ranson's score and modified CTSI in predicting the severity of acute pancreatitis based on the 2012 revised Atlanta Classification. Gastroenterol Rep (Oxf) 2018; 6 (02) 127-131
  • 17 Valverde-López F, Matas-Cobos AM, Alegría-Motte C, Jiménez-Rosales R, Úbeda-Muñoz M, Redondo-Cerezo E. BISAP, RANSON, lactate and others biomarkers in prediction of severe acute pancreatitis in a European cohort. J Gastroenterol Hepatol 2017; 32 (09) 1649-1656
  • 18 Lankisch PG, Mahlke R, Blum T. et al. Hemoconcentration: an early marker of severe and/or necrotizing pancreatitis? A critical appraisal. Am J Gastroenterol 2001; 96 (07) 2081-2085
  • 19 Staubli SM, Oertli D, Nebiker CA. Laboratory markers predicting severity of acute pancreatitis. Crit Rev Clin Lab Sci 2015; 52 (06) 273-283
  • 20 Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach. Gastroenterology 2019; 156 (07) 1994-2007.e3
  • 21 Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13 (4, Suppl 2): e1-e15
  • 22 Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association Clinical Practice update: management of pancreatic necrosis. Gastroenterology 2020; 158 (01) 67-75.e1
  • 23 Kamal A, Singh VK, Akshintala VS. et al. CT and MRI assessment of symptomatic organized pancreatic fluid collections and pancreatic duct disruption: an interreader variability study using the revised Atlanta classification 2012. Abdom Imaging 2015; 40 (06) 1608-1616
  • 24 Muthusamy VR, Chandrasekhara V, Acosta RD. et al; ASGE Standards of Practice Committee. The role of endoscopy in the diagnosis and treatment of inflammatory pancreatic fluid collections. Gastrointest Endosc 2016; 83 (03) 481-488
  • 25 Arvanitakis M, Dumonceau JM, Albert J. et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy 2018; 50 (05) 524-546
  • 26 Pezzilli R, Zerbi A, Campra D. et al; Italian Association for the Study of the Pancreas (AISP). Consensus guidelines on severe acute pancreatitis. Dig Liver Dis 2015; 47 (07) 532-543
  • 27 Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013; 108 (09) 1400-1415 , 1416
  • 28 Trikudanathan G, Attam R, Arain MA, Mallery S, Freeman ML. Endoscopic interventions for necrotizing pancreatitis. Am J Gastroenterol 2014; 109 (07) 969-981 , quiz 982
  • 29 Umapathy C, Gajendran M, Mann R. et al. Pancreatic fluid collections: clinical manifestations, diagnostic evaluation and management. Dis Mon 2020; 66 (11) 100986
  • 30 Dhaka N, Samanta J, Kochhar S. et al. Pancreatic fluid collections: What is the ideal imaging technique?. World J Gastroenterol 2015; 21 (48) 13403-13410
  • 31 Xiao B, Xu HB, Jiang ZQ, Zhang J, Zhang XM. Current concepts for the diagnosis of acute pancreatitis by multiparametric magnetic resonance imaging. Quant Imaging Med Surg 2019; 9 (12) 1973-1985
  • 32 Agalianos C, Passas I, Sideris I, Davides D, Dervenis C. Review of management options for pancreatic pseudocysts. Transl Gastroenterol Hepatol 2018; 3: 18
  • 33 Medarapalem JB, Appasani S, Gulati A. et al. Mo1460 characterization of fluid collections using quantification of solid debris in acute pancreatitis-a comparative study of EUS vs. CT for prediction of intervention. Gastrointest Endosc 2014; 79 (05) AB445
  • 34 Besselink MG, Verwer TJ, Schoenmaeckers EJ. et al. Timing of surgical intervention in necrotizing pancreatitis. Arch Surg 2007; 142 (12) 1194-1201
  • 35 Fernández-del Castillo C, Rattner DW, Makary MA, Mostafavi A, McGrath D, Warshaw AL. Débridement and closed packing for the treatment of necrotizing pancreatitis. Ann Surg 1998; 228 (05) 676-684
  • 36 van Dijk SM, Hallensleben NDL, van Santvoort HC. et al; Dutch Pancreatitis Study Group. Acute pancreatitis: recent advances through randomised trials. Gut 2017; 66 (11) 2024-2032
  • 37 Ge PS, Weizmann M, Watson RR. Pancreatic pseudocysts: advances in endoscopic management. Gastroenterol Clin North Am 2016; 45 (01) 9-27
  • 38 Misra D, Sood T. Pancreatic Pseudocyst. Treasure Island, FL: StatPearls Publishing; 2021. PMID: 32491526
  • 39 Aghdassi A, Mayerle J, Kraft M, Sielenkämper AW, Heidecke CD, Lerch MM. Diagnosis and treatment of pancreatic pseudocysts in chronic pancreatitis. Pancreas 2008; 36 (02) 105-112 [ Erratum in: Pancreas 2008;37(2):240. PMID: 18376299]
  • 40 Andalib I, Dawod E, Kahaleh M. Modern management of pancreatic fluid collections. J Clin Gastroenterol 2018; 52 (02) 97-104
  • 41 Aghdassi AA, Mayerle J, Kraft M, Sielenkämper AW, Heidecke CD, Lerch MM. Pancreatic pseudocysts–when and how to treat?. HPB (Oxford) 2006; 8 (06) 432-441
  • 42 Warshaw AL, Rattner DW. Timing of surgical drainage for pancreatic pseudocyst. Clinical and chemical criteria. Ann Surg 1985; 202 (06) 720-724
  • 43 Elmunzer BJ. Endoscopic drainage of pancreatic fluid collections. Clin Gastroenterol Hepatol 2018; 16 (12) 1851-1863.e3
  • 44 Akshintala VS, Saxena P, Zaheer A. et al. A comparative evaluation of outcomes of endoscopic versus percutaneous drainage for symptomatic pancreatic pseudocysts. Gastrointest Endosc 2014; 79 (06) 921-928 , quiz 983.e2, 983.e5
  • 45 Keane MG, Sze SF, Cieplik N. et al. Endoscopic versus percutaneous drainage of symptomatic pancreatic fluid collections: a 14-year experience from a tertiary hepatobiliary centre. Surg Endosc 2016; 30 (09) 3730-3740
  • 46 Runzi M, Niebel W, Goebell H, Gerken G, Layer P. Severe acute pancreatitis: nonsurgical treatment of infected necroses. Pancreas 2005; 30 (03) 195-199
  • 47 Mouli VP, Sreenivas V, Garg PK. Efficacy of conservative treatment, without necrosectomy, for infected pancreatic necrosis: a systematic review and meta-analysis. Gastroenterology 2013; 144 (02) 333-340.e2
  • 48 Lee JK, Kwak KK, Park JK. et al. The efficacy of nonsurgical treatment of infected pancreatic necrosis. Pancreas 2007; 34 (04) 399-404
  • 49 Garg PK, Sharma M, Madan K, Sahni P, Banerjee D, Goyal R. Primary conservative treatment results in mortality comparable to surgery in patients with infected pancreatic necrosis. Clin Gastroenterol Hepatol 2010; 8 (12) 1089-1094.e2
  • 50 Tyberg A, Karia K, Gabr M. et al. Management of pancreatic fluid collections: a comprehensive review of the literature. World J Gastroenterol 2016; 22 (07) 2256-2270
  • 51 Khan MA, Hammad T, Khan Z. et al. Endoscopic versus percutaneous management for symptomatic pancreatic fluid collections: a systematic review and meta-analysis. Endosc Int Open 2018; 6 (04) E474-E483
  • 52 Acosta RD, Abraham NS, Chandrasekhara V. et al; ASGE Standards of Practice Committee. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016; 83 (01) 3-16
  • 53 Mönkemüller KE, Baron TH, Morgan DE. Transmural drainage of pancreatic fluid collections without electrocautery using the Seldinger technique. Gastrointest Endosc 1998; 48 (02) 195-200
  • 54 Barthet M, Sahel J, Bodiou-Bertei C, Bernard JP. Endoscopic transpapillary drainage of pancreatic pseudocysts. Gastrointest Endosc 1995; 42 (03) 208-213
  • 55 Binmoeller KF, Seifert H, Walter A, Soehendra N. Transpapillary and transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 1995; 42 (03) 219-224
  • 56 Kahaleh M, Shami VM, Conaway MR. et al. Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective comparison with conventional endoscopic drainage. Endoscopy 2006; 38 (04) 355-359
  • 57 Varadarajulu S, Christein JD, Tamhane A, Drelichman ER, Wilcox CM. Prospective randomized trial comparing EUS and EGD for transmural drainage of pancreatic pseudocysts (with videos). Gastrointest Endosc 2008; 68 (06) 1102-1111
  • 58 Park DH, Lee SS, Moon SH. et al. Endoscopic ultrasound-guided versus conventional transmural drainage for pancreatic pseudocysts: a prospective randomized trial. Endoscopy 2009; 41 (10) 842-848
  • 59 Samuelson AL, Shah RJ. Endoscopic management of pancreatic pseudocysts. Gastroenterol Clin North Am 2012; 41 (01) 47-62
  • 60 Panamonta N, Ngamruengphong S, Kijsirichareanchai K, Nugent K, Rakvit A. Endoscopic ultrasound-guided versus conventional transmural techniques have comparable treatment outcomes in draining pancreatic pseudocysts. Eur J Gastroenterol Hepatol 2012; 24 (12) 1355-1362
  • 61 Holt BA, Varadarajulu S. The endoscopic management of pancreatic pseudocysts (with videos). Gastrointest Endosc 2015; 81 (04) 804-812
  • 62 Catalano MF, Geenen JE, Schmalz MJ, Johnson GK, Dean RS, Hogan WJ. Treatment of pancreatic pseudocysts with ductal communication by transpapillary pancreatic duct endoprosthesis. Gastrointest Endosc 1995; 42 (03) 214-218
  • 63 Varadarajulu S, Noone TC, Tutuian R, Hawes RH, Cotton PB. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc 2005; 61 (04) 568-575
  • 64 Smith MT, Sherman S, Ikenberry SO, Hawes RH, Lehman GA. Alterations in pancreatic ductal morphology following polyethylene pancreatic stent therapy. Gastrointest Endosc 1996; 44 (03) 268-275
  • 65 Cremer M, Deviere J, Engelholm L. Endoscopic management of cysts and pseudocysts in chronic pancreatitis: long-term follow-up after 7 years of experience. Gastrointest Endosc 1989; 35 (01) 1-9
  • 66 Varadarajulu S, Phadnis MA, Christein JD, Wilcox CM. Multiple transluminal gateway technique for EUS-guided drainage of symptomatic walled-off pancreatic necrosis. Gastrointest Endosc 2011; 74 (01) 74-80
  • 67 Thompson CC, Kumar N, Slattery J. et al. A standardized method for endoscopic necrosectomy improves complication and mortality rates. Pancreatology 2016; 16 (01) 66-72
  • 68 van Brunschot S, van Grinsven J, van Santvoort HC. et al; Dutch Pancreatitis Study Group. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391 (10115): 51-58
  • 69 Seewald S, Groth S, Omar S. et al. Aggressive endoscopic therapy for pancreatic necrosis and pancreatic abscess: a new safe and effective treatment algorithm (videos). Gastrointest Endosc 2005; 62 (01) 92-100
  • 70 Gardner TB, Coelho-Prabhu N, Gordon SR. et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc 2011; 73 (04) 718-726
  • 71 Seifert H, Biermer M, Schmitt W. et al. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with long-term follow-up (the GEPARD Study). Gut 2009; 58 (09) 1260-1266
  • 72 Bakker OJ, van Santvoort HC, van Brunschot S. et al; Dutch Pancreatitis Study Group. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. JAMA 2012; 307 (10) 1053-1061
  • 73 van Brunschot S, van Grinsven J, Voermans RP. et al; Dutch Pancreatitis Study Group. Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711]. BMC Gastroenterol 2013; 13: 161
  • 74 Bang JY, Arnoletti JP, Holt BA. et al. An endoscopic transluminal approach, compared with minimally invasive surgery, reduces complications and costs for patients with necrotizing pancreatitis. Gastroenterology 2019; 156 (04) 1027-1040.e3
  • 75 van Brunschot S, Hollemans RA, Bakker OJ. et al. Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients. Gut 2018; 67 (04) 697-706
  • 76 Bang JY, Wilcox CM, Trevino JM. et al. Relationship between stent characteristics and treatment outcomes in endoscopic transmural drainage of uncomplicated pancreatic pseudocysts. Surg Endosc 2014; 28 (10) 2877-2883
  • 77 Varadarajulu S, Bang JY, Phadnis MA, Christein JD, Wilcox CM. Endoscopic transmural drainage of peripancreatic fluid collections: outcomes and predictors of treatment success in 211 consecutive patients. J Gastrointest Surg 2011; 15 (11) 2080-2088
  • 78 Lee BU, Song TJ, Lee SS. et al. Newly designed, fully covered metal stents for endoscopic ultrasound (EUS)-guided transmural drainage of peripancreatic fluid collections: a prospective randomized study. Endoscopy 2014; 46 (12) 1078-1084
  • 79 Sharaiha RZ, DeFilippis EM, Kedia P. et al. Metal versus plastic for pancreatic pseudocyst drainage: clinical outcomes and success. Gastrointest Endosc 2015; 82 (05) 822-827
  • 80 Bang JY, Hawes R, Bartolucci A, Varadarajulu S. Efficacy of metal and plastic stents for transmural drainage of pancreatic fluid collections: a systematic review. Dig Endosc 2015; 27 (04) 486-498
  • 81 Penn DE, Draganov PV, Wagh MS, Forsmark CE, Gupte AR, Chauhan SS. Prospective evaluation of the use of fully covered self-expanding metal stents for EUS-guided transmural drainage of pancreatic pseudocysts. Gastrointest Endosc 2012; 76 (03) 679-684
  • 82 Binmoeller KF, Shah J. A novel lumen-apposing stent for transluminal drainage of nonadherent extraintestinal fluid collections. Endoscopy 2011; 43 (04) 337-342
  • 83 Rodrigues-Pinto E, Baron TH. Evaluation of the AXIOS stent for the treatment of pancreatic fluid collections. Expert Rev Med Devices 2016; 13 (09) 793-805
  • 84 Sharaiha RZ, Tyberg A, Khashab MA. et al. Endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis. Clin Gastroenterol Hepatol 2016; 14 (12) 1797-1803
  • 85 DeSimone ML, Asombang AW, Berzin TM. Lumen apposing metal stents for pancreatic fluid collections: recognition and management of complications. World J Gastrointest Endosc 2017; 9 (09) 456-463
  • 86 Bang JY, Navaneethan U, Hasan MK, Sutton B, Hawes R, Varadarajulu S. Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomised trial. Gut 2019; 68 (07) 1200-1209