Content uploaded by Pankaj Gupta
Author content
All content in this area was uploaded by Pankaj Gupta on Jul 06, 2022
Content may be subject to copyright.
World Journal of
Clinical Cases
ISSN 2307-8960 (online)
World J Clin Cases 2022 July 16; 10(20): 6759-7186
Published by Baishideng Publishing Group Inc
WJCC https://www.wjgnet.com IJuly 16, 2022 Volume 10 Issue 20
World Journal of
Clinical Cases
W J C C
Contents Thrice Monthly Volume 10 Number 20 July 16, 2022
OPINION REVIEW
Semaglutide might be a key for breaking the vicious cycle of metabolically associated fatty liver disease
spectrum?
6759
Cigrovski Berkovic M, Rezic T, Bilic-Curcic I, Mrzljak A
MINIREVIEWS
Drainage of pancreatic fluid collections in acute pancreatitis: A comprehensive overview
6769
Bansal A, Gupta P, Singh AK, Shah J, Samanta J, Mandavdhare HS, Sharma V, Sinha SK, Dutta U, Sandhu MS, Kochhar R
Frontiers of COVID-19-related myocarditis as assessed by cardiovascular magnetic resonance
6784
Luo Y, Liu BT, Yuan WF, Zhao CX
ORIGINAL ARTICLE
Case Control Study
Urinary and sexual function changes in benign prostatic hyperplasia patients before and after
transurethral columnar balloon dilatation of the prostate
6794
Zhang DP, Pan ZB, Zhang HT
Effects of the information–knowledge–attitude–practice nursing model combined with predictability
intervention on patients with cerebrovascular disease
6803
Huo HL, Gui YY, Xu CM, Zhang Y, Li Q
Retrospective Cohort Study
Effects of Kampo medicine hangebyakujutsutemmato on persistent postural-perceptual dizziness: A
retrospective pilot study
6811
Miwa T, Kanemaru SI
Retrospective Study
Longitudinal changes in personalized platelet count metrics are good indicators of initial 3-year outcome
in colorectal cancer
6825
Herold Z, Herold M, Lohinszky J, Szasz AM, Dank M, Somogyi A
Efficacy of Kegel exercises in preventing incontinence after partial division of internal anal sphincter
during anal fistula surgery
6845
Garg P, Yagnik VD, Kaur B, Menon GR, Dawka S
Observational Study
Influence of the water jet system vs cavitron ultrasonic surgical aspirator for liver resection on the remnant
liver
6855
Hanaki T, Tsuda A, Sunaguchi T, Goto K, Morimoto M, Murakami Y, Kihara K, Matsunaga T, Yamamoto M, Tokuyasu N,
Sakamoto T, Hasegawa T, Fujiwara Y
WJCC https://www.wjgnet.com II July 16, 2022 Volume 10 Issue 20
World Journal of Clinical Cases
Contents Thrice Monthly Volume 10 Number 20 July 16, 2022
Critical values of monitoring indexes for perioperative major adverse cardiac events in elderly patients
with biliary diseases
6865
Zhang ZM, Xie XY, Zhao Y, Zhang C, Liu Z, Liu LM, Zhu MW, Wan BJ, Deng H, Tian K, Guo ZT, Zhao XZ
Comparative study of surface electromyography of masticatory muscles in patients with different types of
bruxism
6876
Lan KW, Jiang LL, Yan Y
Randomized Controlled Trial
Dural puncture epidural technique provides better anesthesia quality in repeat cesarean delivery than
epidural technique: Randomized controlled study
6890
Wang SY, He Y, Zhu HJ, Han B
SYSTEMATIC REVIEWS
Network pharmacology-based strategy for predicting therapy targets of Sanqi and Huangjing in diabetes
mellitus
6900
Cui XY, Wu X, Lu D, Wang D
META-ANALYSIS
Endoscopic submucosal dissection for early signet ring cell gastric cancer: A systematic review and meta-
analysis
6915
Weng CY, Sun SP, Cai C, Xu JL, Lv B
Prognostic value of computed tomography derived skeletal muscle mass index in lung cancer: A meta-
analysis
6927
Pan XL, Li HJ, Li Z, Li ZL
CASE REPORT
Autosomal dominant osteopetrosis type II resulting from a de novo mutation in the CLCN7 gene: A case
report
6936
Song XL, Peng LY, Wang DW, Wang H
Clinical expression and mitochondrial deoxyribonucleic acid study in twins with 14484 Leber’s hereditary
optic neuropathy: A case report
6944
Chuenkongkaew WL, Chinkulkitnivat B, Lertrit P, Chirapapaisan N, Kaewsutthi S, Suktitipat B, Mitrpant C
Management of the enteroatmospheric fistula: A case report
6954
Cho J, Sung K, Lee D
Lower lip recurrent keratoacanthoma: A case report
6960
Liu XG, Liu XG, Wang CJ, Wang HX, Wang XX
Optic disc coloboma associated with macular retinoschisis: A case report
6966
Zhang W, Peng XY
WJCC https://www.wjgnet.com III July 16, 2022 Volume 10 Issue 20
World Journal of Clinical Cases
Contents Thrice Monthly Volume 10 Number 20 July 16, 2022
A 7-year-old boy with recurrent cyanosis and tachypnea: A case report
6974
Li S, Chen LN, Zhong L
Schwannomatosis patient who was followed up for fifteen years: A case report
6981
Li K, Liu SJ, Wang HB, Yin CY, Huang YS, Guo WT
Intentional replantation combined root resection therapy for the treatment of type III radicular groove
with two roots: A case report
6991
Tan D, Li ST, Feng H, Wang ZC, Wen C, Nie MH
Clinical features and genetic variations of severe neonatal hyperbilirubinemia: Five case reports
6999
Lin F, Xu JX, Wu YH, Ma YB, Yang LY
Percutaneous transhepatic access for catheter ablation of a patient with heterotaxy syndrome complicated
with atrial fibrillation: A case report
7006
Wang HX, Li N, An J, Han XB
Secondary positioning of rotationally asymmetric refractive multifocal intraocular lens in a patient with
glaucoma: A case report
7013
Fan C, Zhou Y, Jiang J
Laparoscopic repair of diaphragmatic hernia associating with radiofrequency ablation for hepatocellular
carcinoma: A case report
7020
Tsunoda J, Nishi T, Ito T, Inaguma G, Matsuzaki T, Seki H, Yasui N, Sakata M, Shimada A, Matsumoto H
Hypopituitary syndrome with pituitary crisis in a patient with traumatic shock: A case report
7029
Zhang XC, Sun Y
Solitary plasmacytoma of the left rib misdiagnosed as angina pectoris: A case report
7037
Yao J, He X, Wang CY, Hao L, Tan LL, Shen CJ, Hou MX
Secondary coronary artery ostial lesions: Three case reports
7045
Liu XP, Wang HJ, Gao JL, Ma GL, Xu XY, Ji LN, He RX, Qi BYE, Wang LC, Li CQ, Zhang YJ, Feng YB
Bladder perforation injury after percutaneous peritoneal dialysis catheterization: A case report
7054
Shi CX, Li ZX, Sun HT, Sun WQ, Ji Y, Jia SJ
Myotonic dystrophy type 1 presenting with dyspnea: A case report
7060
Jia YX, Dong CL, Xue JW, Duan XQ, Xu MY, Su XM, Li P
Novel mutation in the SALL1 gene in a four-generation Chinese family with uraemia: A case report
7068
Fang JX, Zhang JS, Wang MM, Liu L
Malignant transformation of primary mature teratoma of colon: A case report
7076
Liu J
WJCC https://www.wjgnet.com IX July 16, 2022 Volume 10 Issue 20
World Journal of Clinical Cases
Contents Thrice Monthly Volume 10 Number 20 July 16, 2022
Treatment of pyogenic liver abscess by surgical incision and drainage combined with platelet-rich plasma:
A case report
7082
Wang JH, Gao ZH, Qian HL, Li JS, Ji HM, Da MX
Left bundle branch pacing in a ventricular pacing dependent patient with heart failure: A case report
7090
Song BX, Wang XX, An Y, Zhang YY
Solitary fibrous tumor of the liver: A case report and review of the literature
7097
Xie GY, Zhu HB, Jin Y, Li BZ, Yu YQ, Li JT
MutL homolog 1 germline mutation c.(453+1_454-1)_(545+1_546-1)del identified in lynch syndrome: A
case report and review of literature
7105
Zhang XW, Jia ZH, Zhao LP, Wu YS, Cui MH, Jia Y, Xu TM
Malignant histiocytosis associated with mediastinal germ cell tumor: A case report
7116
Yang PY, Ma XL, Zhao W, Fu LB, Zhang R, Zeng Q, Qin H, Yu T, Su Y
Immunoglobulin G4 associated autoimmune cholangitis and pancreatitis following the administration of
nivolumab: A case report
7124
Agrawal R, Guzman G, Karimi S, Giulianotti PC, Lora AJM, Jain S, Khan M, Boulay BR, Chen Y
Portal vein thrombosis in a noncirrhotic patient after hemihepatectomy: A case report and review of
literature
7130
Zhang SB, Hu ZX, Xing ZQ, Li A, Zhou XB, Liu JH
Microvascular decompression for a patient with oculomotor palsy caused by posterior cerebral artery
compression: A case report and literature review
7138
Zhang J, Wei ZJ, Wang H, Yu YB, Sun HT
Topical halometasone cream combined with fire needle pre-treatment for treatment of primary cutaneous
amyloidosis: Two case reports
7147
Su YQ, Liu ZY, Wei G, Zhang CM
Simultaneous robot-assisted approach in a super-elderly patient with urothelial carcinoma and
synchronous contralateral renal cell carcinoma: A case report
7153
Yun JK, Kim SH, Kim WB, Kim HK, Lee SW
Nursing a patient with latent autoimmune diabetes in adults with insulin-related lipodystrophy, allergy,
and exogenous insulin autoimmune syndrome: A case report
7163
He F, Xu LL, Li YX, Dong YX
Incidental diagnosis of medullary thyroid carcinoma due to persistently elevated procalcitonin in a patient
with COVID-19 pneumonia: A case report
7171
Saha A, Mukhopadhyay M, Paul S, Bera A, Bandyopadhyay T
Macular hole following phakic intraocular lens implantation: A case report
7178
Li XJ, Duan JL, Ma JX, Shang QL
WJCC https://www.wjgnet.com XJuly 16, 2022 Volume 10 Issue 20
World Journal of Clinical Cases
Contents Thrice Monthly Volume 10 Number 20 July 16, 2022
LETTER TO THE EDITOR
Is every microorganism detected in the intensive care unit a nosocomial infection? Isn’t prevention more
important than detection?
7184
Yildirim F, Karaman I, Yildirim M
WJCC https://www.wjgnet.com XI July 16, 2022 Volume 10 Issue 20
World Journal of Clinical Cases
Contents Thrice Monthly Volume 10 Number 20 July 16, 2022
ABOUT COVER
Editorial Board Member of World Journal of Clinical Cases, Jie-Feng Huang, PhD, Associate Chief Physician,
Associate Professor, Department of Orthopaedics and Traumatology, The First Affiliated Hospital of Zhejiang
Chinese Medical University, Hangzhou 310006, Zhejiang Province, China. 40983285@qq.com
AIMS AND SCOPE
The primary aim of World Journal of Clinical Cases (WJCC, World J Clin Cases) is to provide scholars and readers from
various fields of clinical medicine with a platform to publish high-quality clinical research articles and
communicate their research findings online.
WJCC mainly publishes articles reporting research results and findings obtained in the field of clinical medicine
and covering a wide range of topics, including case control studies, retrospective cohort studies, retrospective
studies, clinical trials studies, observational studies, prospective studies, randomized controlled trials, randomized
clinical trials, systematic reviews, meta-analysis, and case reports.
INDEXING/ABSTRACTING
The WJCC is now indexed in Science Citation Index Expanded (also known as SciSearch®), Journal Citation
Reports/Science Edition, Scopus, PubMed, and PubMed Central. The 2021 Edition of Journal Citation Reports®
cites the 2020 impact factor (IF) for WJCC as 1.337; IF without journal self cites: 1.301; 5-year IF: 1.742; Journal
Citation Indicator: 0.33; Ranking: 119 among 169 journals in medicine, general and internal; and Quartile category:
Q3. The WJCC's CiteScore for 2020 is 0.8 and Scopus CiteScore rank 2020: General Medicine is 493/793.
RESPONSIBLE EDITORS FOR THIS ISSUE
Production Editor: Hua-Ge Yu; Production Department Director: Xu Guo; Editorial Office Director: Jin-Lei Wang.
NAME OF JOURNAL INSTRUCTIONS TO AUTHORS
World Journal of Clinical Cases https://www.wjgnet.com/bpg/gerinfo/204
ISSN GUIDELINES FOR ETHICS DOCUMENTS
ISSN 2307-8960 (online) https://www.wjgnet.com/bpg/GerInfo/287
LAUNCH DATE GUIDELINES FOR NON-NATIVE SPEAKERS OF ENGLISH
April 16, 2013 https://www.wjgnet.com/bpg/gerinfo/240
FREQUENCY PUBLICATION ETHICS
Thrice Monthly https://www.wjgnet.com/bpg/GerInfo/288
EDITORS-IN-CHIEF PUBLICATION MISCONDUCT
Bao-Gan Peng, Jerzy Tadeusz Chudek, George Kontogeorgos, Maurizio Serati, Ja
Hyeon Ku
https://www.wjgnet.com/bpg/gerinfo/208
EDITORIAL BOARD MEMBERS ARTICLE PROCESSING CHARGE
https://www.wjgnet.com/2307-8960/editorialboard.htm https://www.wjgnet.com/bpg/gerinfo/242
PUBLICATION DATE STEPS FOR SUBMITTING MANUSCRIPTS
July 16, 2022 https://www.wjgnet.com/bpg/GerInfo/239
COPYRIGHT ONLINE SUBMISSION
© 2022 Baishideng Publishing Group Inc https://www.f6publishing.com
© 2022 Baishideng Publishing Group Inc. All rights reserved. 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
E-mail: bpgoffice@wjgnet.com https://www.wjgnet.com
WJCC https://www.wjgnet.com 6769 July 16, 2022 Volume 10 Issue 20
World Journal of
Clinical Cases
W J C C
Submit a Manuscript: https://www.f6publishing.com World J Clin Cases 2022 July 16; 10(20): 6769-6783
DOI: 10.12998/wjcc.v10.i20.6769 ISSN 2307-8960 (online)
MINIREVIEWS
Drainage of pancreatic fluid collections in acute pancreatitis: A
comprehensive overview
Akash Bansal, Pankaj Gupta, Anupam K Singh, Jimil Shah, Jayanta Samanta, Harshal S Mandavdhare, Vishal
Sharma, Saroj Kant Sinha, Usha Dutta, Manavjit Singh Sandhu, Rakesh Kochhar
Specialty type: Gastroenterology
and hepatology
Provenance and peer review:
Invited article; Externally peer
reviewed.
Peer-review model: Single blind
Peer-review report’s scientific
quality classification
Grade A (Excellent): 0
Grade B (Very good): 0
Grade C (Good): C, C
Grade D (Fair): 0
Grade E (Poor): 0
P-Reviewer: Angelico R, Italy; Zhao
CF, China
Received: October 26, 2021
Peer-review started: October 26,
2021
First decision: December 27, 2021
Revised: January 10, 2022
Accepted: May 13, 2022
Article in press: May 13, 2022
Published online: July 16, 2022
Akash Bansal, Pankaj Gupta, Manavjit Singh Sandhu, Department of Radiodiagnosis,
Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
Anupam K Singh, Jimil Shah, Jayanta Samanta, Harshal S Mandavdhare, Vishal Sharma, Saroj
Kant Sinha, Usha Dutta, Rakesh Kochhar, Department of Gastroenterology, Postgraduate
Institute of Medical Education and Research, Chandigarh 160012, India
Corresponding author: Pankaj Gupta, MBBS, MD, Associate Professor, Department of
Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Sector 12,
Chandigarh 160012, India. pankajgupta959@gmail.com
Abstract
Moderately severe and severe acute pancreatitis is characterized by local and
systemic complications. Systemic complications predominate the early phase of
acute pancreatitis while local complications are important in the late phase of the
disease. Necrotic fluid collections represent the most important local com-
plication. Drainage of these collections is indicated in the setting of infection,
persistent or new onset organ failure, compressive or pressure symptoms, and
intraabdominal hypertension. Percutaneous, endoscopic, and minimally invasive
surgical drainage represents the various methods of drainage with each having its
own advantages and disadvantages. These methods are often complementary. In
this minireview, we discuss the indications, timing, and techniques of drainage of
pancreatic fluid collections with focus on percutaneous catheter drainage. We also
discuss the novel methods and techniques to improve the outcomes of
percutaneous catheter drainage.
Key Words: Pancreatitis, Acute necrotizing; Drainage; Catheters; Stents; Therapeutic
irrigation; Debridement; Collections
©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6770 July 16, 2022 Volume 10 Issue 20
Core Tip: Percutaneous catheter drainage is an important method for drainage of pancreatic fluid
collections. In the early stage of the disease (2-4 wk), it is often the method of choice. It is shown to be
effective alone in almost 50% of the patients. It is also an important part of the dual modality treatment
that involves endoscopic drainage. It acts as a gateway for percutaneous endoscopic and minimally
invasive surgical necrosectomy. There is evolving data regarding the indications and timing of drainage.
Additionally, there are several recent studies describing methods to improve the percutaneous catheter
drainage outcomes.
Citation: Bansal A, Gupta P, Singh AK, Shah J, Samanta J, Mandavdhare HS, Sharma V, Sinha SK, Dutta U,
Sandhu MS, Kochhar R. Drainage of pancreatic fluid collections in acute pancreatitis: A comprehensive overview.
World J Clin Cases 2022; 10(20): 6769-6783
URL: https://www.wjgnet.com/2307-8960/full/v10/i20/6769.htm
DOI: https://dx.doi.org/10.12998/wjcc.v10.i20.6769
INTRODUCTION
Acute pancreatitis (AP) is an acute inflammatory condition of the pancreas and one of the common
causes of acute abdomen presenting as a medical emergency. Severity ranges from mild to moderately
severe AP (MSAP) and severe AP disease (SAP). Mild AP has an excellent prognosis with conservative
treatment[1,2]. In patients having infected necrosis or organ failure (OF), mortality rises to about 30%
despite invasive and surgical management[1].
According to the revised Atlanta classification (RAC), AP is divided into early (< 1 wk) and late (> 1
wk) phases. The early phase is characterised by systemic inflammatory response and the late phase
characterized by persistent OF or systemic complications[1]. Based on imaging findings, AP is divided
into interstitial edematous pancreatitis (IEP) and acute necrotizing pancreatitis depending on the
presence of necrosis (pancreatic, peripancreatic or both)[1,2].
Pancreatic fluid collections (PFCs) represent important local complications of AP. Not all PFCs are
necrotic and not all necrotic collections are infected. Therefore, RAC provided an important distinction
between the collections which contained purely fluid contents and those which also contained necrotic
debris. PFCs associated with IEP are called acute peripancreatic fluid collections (APFCs; ≤ 4 wk) and
pseudocysts (> 4 wk); and those associated with necrosis are called acute necrotic collections (ANCs ≤ 4
wk) and walled off necrosis (WON; > 4 wk) (Figure 1). Any of the above mentioned collections can get
infected and require intervention[1,2]. Recent studies have highlighted that 4 wk threshold for classi-
fication of PFCs is imprecise. In fact, many collections have partial/clinically significant encapsulation
in the 3rd week of illness[3-5].
Management of AP and its complications requires a multidisciplinary approach involving gastroen-
terologists, interventional radiologists, and surgeons. Conservative management is the rule in the early
phase of AP, which includes fluid resuscitation, pain control, prophylactic antibodies, and oxygen and
nutritional support. Antibiotic treatment should be initiated only in culture proven infection or when
there is strong clinical suspicion of infection. They should not be given prophylactically[6]. Enteral
feeding may become necessary to bypass the inflamed region of the bowel adjacent to the pancreas and
may be achieved by nasojejunal tube or percutaneous jejunostomy[6,7]. PFCs can be treated conser-
vatively or by percutaneous, endoscopic, or surgical methods depending on their nature[7,8].
There has been a paradigm shift in the treatment of necrotizing pancreatitis from open necrosectomy
to a minimally invasive step-up approach after the publication of results of a large randomized
controlled trial (PANTER trial), in which it was seen that 35% of the patients did not require any further
intervention and patients managed with the step-up approach had a significantly lower incidence of
new onset organ failure and diabetes[9]. This step-up approach is thus now the standard of care for all
pancreatitis patients, with upgradations done if there was no clinical improvement or catheter
displacement was seen (Figure 2)[9,10].
In this review, we outline the various minimally invasive intervention techniques (predominantly
percutaneous with few salient endoscopic techniques), their indications, timing, image guidance,
complications, and factors predicting response, so that an interventional radiologist can take an
informed decision on when and why to drain a PFC.
INDICATIONS OF DRAINAGE
The standard indication of drainage of a PFC is infected necrosis, preferably at the stage of WON
(usually after 3-4 wk)[11,12]. The drainage can be either percutaneous catheter drainage (PCD),
endoscopic drainage (ED), or surgical debridement. Infection can be documented by the presence of gas
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6771 July 16, 2022 Volume 10 Issue 20
Figure 1 Various types of pancreatic fluid collections according to revised Atlanta classification. A: Acute peripancreatic fluid collection (arrow);
B: Acute necrotic collection; C: Pseudocyst; D: Walled off necrosis with air foci (arrow) in the collection.
Figure 2 Step-up approach to management of pancreatic fluid collections. A: Lesser sac collection with 14 F pigtail in-situ which was upgraded to 18
F; B: The patients later underwent endoscopic cystogastrostomy and necrosectomy (not shown).
on computed tomography (CT) (Figure 1D) or microbial growth on fine needle aspiration (FNA). The
latter is now not commonly utilized as it has a high false negative rate (up to 25%)[13]. Additionally,
there is a theoretical risk of introduction of infection into sterile collection[14]. According to a survey,
most pancreatologists did not routinely perform FNA and 15% never performed FNA[15]. A strong
suspicion of infected necrosis is based on clinical deterioration or fever in the absence of other sources of
infection[7,12]. Persistent OF for several weeks in the presence of ANC or WON without evidence of
infection is also an accepted indication for intervention[12].
However, there are several evolving indications to intervene either early, or in the absence of
infection or persistent OF. These include mass effect caused by large collections causing either bowel or
biliary obstruction, disconnected pancreatic syndrome, “persistent unwellness” (continued anorexia,
intractable pain, and weight loss), or abdominal compartment syndrome (which is an emergency
indication) (Figure 3)[12,14,16]. Most of these evolving indications would require a percutaneous
intervention as endoscopic interventions generally require a walled off collection and a suitable location
adjacent to the gastrointestinal tract, and cannot usually be undertaken in an emergency setting.
Collections which do not require drainage include asymptomatic WONs, non-infected pseudocysts or
APFCs and collections which drain through spontaneous gastrointestinal fistulas[12,17].
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6772 July 16, 2022 Volume 10 Issue 20
Figure 3 Evolving indications of drainage. A: Large peripancreatic collection compressing the ampulla (orange arrow) causing biliary dilatation (white arrow);
B: Disconnected pancreatic duct syndrome with dilated pancreatic duct communicating with the collections (arrowheads).
TIMING OF DRAINAGE
Standard recommendation
Any intervention of PFC, if performed in an acutely ill patient in the early phase of AP, is associated
with high morbidity and mortality due to heightened systemic inflammation response at this time and
an increased risk of haemorrhage[7]. Thus, current guidelines suggest delaying interventions (whether
percutaneous, endoscopic, or surgical) to more than 3-4 wk after disease onset to decrease this
morbidity, as well as to allow encapsulation of the collection[7,12]. This encapsulation allows necrotic
parenchyma to be more clearly defined from normal viable parenchyma which leads to better patient
outcomes and can avoid future pancreatic insufficiency[7,18]. According to the recent American
Gastroenterology Association (AGA) clinical practice guidelines, PCD should be considered in patients
with infected or symptomatic necrotic collections in the early, acute period[6]. In patients with
abdominal compartment syndrome, emergent surgical or radiological intervention can be a life-saving
procedure if medical management fails[12]. Early intervention at the ANC stage may also be required in
patients with suspected or confirmed infected necrosis and persistent OF if medical management alone
is insufficient[7,12].
Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial)
This trial was conducted by the Dutch Pancreatitis Study group to compare early vs standard drainage
in infected pancreatic necrosis. One-hundred and four patients with necrotizing AP were randomized
into two groups-immediate drainage, i.e., within 24 h of diagnosis of infected necrosis, and postponed
drainage group (after walled off stage). Necrosectomy, if needed, was postponed to walled-off stage in
both arms. The primary outcome was comprehensive complication index (CCI) which included all
complications occurring within 6 mo of follow-up, and secondary outcome included mortality, hospital
stay, and intensive care unit (ICU) stay, number of interventions, and quality adjusted life-years. No
difference was seen in CCI between the early and delayed drainage groups, and no difference was seen
in mortality, hospital stay, ICU stay, or complication rates weighted for severity in the two groups.
However, the median number of interventions was significantly higher in the immediate group as
compared to the postponed group[19]. It is important to note that the indication for drainage in this trial
was only infected necrosis and it did not consider other indications as discussed previously.
Recommendations for delayed intervention predominantly stem from an era of open surgical
necrosectomy where early debridement in an acutely ill patient increased the morbidity and mortality
by worsening OF and increasing physiological stress. On the contrary, new hypotheses have suggested
that early and minimally invasive drainage (MID) of PFCs decreases systemic sepsis and allows
maturation of the necrotic collections[7]. Several observational studies have suggested that encapsu-
lation of collections for percutaneous or endoscopic interventions may not be as necessary as for open
surgery, that early intervention (percutaneous or endoscopic) does not have a worse outcome than
delayed intervention, and that some showed significant improvement in organ failure[3,20]. Complic-
ations between early and late interventions were more or less comparable, with late interventions
leading to a significantly higher number of external pancreatic fistulae in one study[4].
Other indications for early drainage
Several other studies have evaluated the role of early drainage in indications other than infected
necrosis, especially OF. Zhang et al[21] conducted a network meta-analysis to compare outcomes of MID
(including ED, PCD, and minimally invasive surgery) and open surgical debridement with conservative
management. It was found that MID decreased both mortality and multiple organ dysfunction
syndrome (MODS) rate compared to conservative management. Early MID (defined as immediate or
early intervention on diagnosis) as well as routine delayed MID also both significantly decreased
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6773 July 16, 2022 Volume 10 Issue 20
mortality and MODS rate compared to conservative treatment. Another study reported improved
outcomes in patients undergoing early PCD of sterile PFC in patients with SAP within 3 d of onset of OF
[22]. The patients with MSAP did not exhibit similar benefit. A single arm retrospective study evaluated
the role of early PCD (< 21 d), with a mean time of intervention of 14.3 ± 2.4 d, for multiple indications,
which showed an overall survival rate of 73.1%. More than 50% of the patients survived on PCD alone,
whereas 19.2% required additional necrosectomy[23].
A single centre randomized controlled trial also evaluated the role of early on-demand drainage vs
standard drainage in ANC and persistent OF[24]. No significant difference was seen in the mortality,
complication rate, length of hospital, or ICU stay between the two groups. However, the authors found
a trend towards reduction in mortality and major complications as well as shorter duration of OF in the
early drainage group.
Thus, early intervention is a feasible technique to treat septic or unstable patients if medical
management alone is insufficient, with no adverse outcome in terms of morbidity and mortality.
TECHNIQUES AND ROUTES OF DRAINAGE
Due to increasing use of minimally invasive interventions and step-up approach, multiple techniques
and routes have been defined for management of PFC. The purpose of intervention could be drainage,
lavage, fragmentation, debridement, or excision[16]. A multidisciplinary consensus conference
categorized the available interventions into open surgical, minimally invasive surgical (laparoscopy or
retroperitoneoscopy), and image-guided percutaneous, endoscopic, or hybrid procedures; and the
routes as transperitoneal, retroperitoneal, or oral routes[16].
According to the recent AGA Clinical Practice Update 2020, percutaneous and endoscopic transmural
interventions are both appropriate first-line management techniques for WON and organized
collections. Endoscopic approach may be preferred as it does not lead to the risk of pancreatocutaneous
fistula. Percutaneous drainage should be considered in patients with infected or symptomatic acute
necrotic collections (< 2 wk) or with WON who are too ill to undergo endoscopic or surgical
interventions. Percutaneous drainage can also be used as an adjunct to ED or as a monotherapy in
collections with deep extensions[7]. Recent studies have shown that PCD alone can lead to successful
treatment in a large number of patients with no further need of additional intervention[11,25].
Endoscopic transmural drainage can be performed either by conventional endoscopic guidance or by
using endoscopic ultrasound (EUS) and is accomplished by using stents (Figure 4A-C)[18]. Endoscopic
stents can be either plastic or metallic with metallic stents showing a better outcome for drainage as they
have larger lumens and permit endoscopic necrosectomy. Newer metallic stents like lumen apposing
metal stents (LAMS) and bi-flanged metal stents prevent stent migration and are even better than earlier
generation metal stents (Figure 4D and E)[6,18,26]. One meta-analysis showed endoscopic and surgical
drainage to be superior to percutaneous catheter drainage in terms of length of hospital stay, recurrence,
and clinical success; however, certain important co-variates were not considered in this study[27]. Sites
of collection were not given due importance as ED can only be done in collections localized to the lesser
sac and not extending to deep locations, where PCD is the initial step in management. The cost of re-
interventions in both endoscopic and percutaneous interventions should also have been taken into
account to describe the cost-effectiveness of either procedure. Also, the studies included in the meta-
analysis only used catheter size between 8-16F, whereas endoscopic stents are far larger. Recent
evidence of aggressive PCD upgradation shows higher success rates as an aggressive protocol of
catheter upsizing every 4-6 d and drainage of all new collections leads to a significantly reduced
hospital and ICU stay as compared to the standard protocol[28].
Thus, despite the increasing utilization of endoscopic and minimally invasive surgical techniques,
PCD remains integral to the management of PFC.
PERCUTANEOUS CATHETER DRAINAGE
PCD can be used as a monotherapy or as an adjunct to ED or as a bridge to surgical necrosectomy. PCD
can be performed under ultrasound (US) or CT guidance. CT guidance is preferred for lesser sac
collections as the bowel is avoided and retroperitoneal insertion is relatively easy. US guidance can be
used in large and superficial collections or when a patient is in sepsis and requires emergent drainage.
Due to its portable nature, it is also very useful in an ICU setting[7,28].
Access routes to the pancreatic collections are chosen to avoid the intestine (to prevent enteric leaks or
contamination of potentially sterile collections) and vessels. Retroperitoneal route through the flank is
the ideal route as it avoids the intestine, prevents disseminated spread of infection through the
peritoneal cavity, and provides access for future minimally invasive surgeries (MIS) (Figure 5A)[8,12].
Transperitoneal route is the second preference in cases where retroperitoneal approach is not possible,
and collections arising from pancreatic head and proximal body are located anteriorly (Figure 5B). Care
should be taken to avoid vessels and other bowel loops when this approach is selected. Transgastric
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6774 July 16, 2022 Volume 10 Issue 20
Figure 4 Endoscopic transmural drainage. A: Endoscopic ultrasound guided transmural puncture of the lesser sac collection with needle tip in situ (arrow); B:
Guidewire (arrow) passed through the needle into the collection; C: Double pigtail cystogastrostomy catheters (arrow) in the partially drained lesser sac collection; D:
Axial; E: Sagittal computed tomography images showing lumen apposing metal stents (arrows).
Figure 5 Routes of percutaneous catheter drainage. A: Retroperitoneal; B: Transperitoneal; C: Transgastric; D: Transhepatic.
approach may be used when there is no bowel free approach to the lesser sac collection, and it is
considered relatively safe due to bacteria free acidic gastric contents (Figure 5C)[8]. Very rarely trans-
hepatic route may have to be used when there is no other feasible route, but it should generally be
avoided (Figure 5D).
PCD can be performed via the Seldinger or the trocar technique. Seldinger technique employs initial
access of the collection by an 18G needle followed by insertion of a 0.035 inch stiff guidewire and serial
dilatation of the tract thereafter. Drainage catheter is then inserted along the guidewire after adequate
dilatation of the tract. Trocar technique employs advancing a co-axial combination of a sharp stylet,
stiffening cannula, and the draining catheter[29]. Seldinger technique is more useful for deep collections
but is more time-consuming as it involves multiple steps. Trocar technique is useful in large and
superficial collections but is more painful[29].
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6775 July 16, 2022 Volume 10 Issue 20
Figure 6 Dual modality drainage in different patients. A: Sagittal sections showing presence of both a lumen apposing metal stent (LAMS-curved arrow)
and a transperitoneal percutaneous catheter (PCD-straight arrow) in the same collection; B: Sagittal section; C: Coronal sections of a patient showing LAMS (curved
arrow) in the lesser sac component and PCD (straight arrow) in the paracolic component of the same collection utilizing advantages of both types of drainages.
Figure 7 Gastrointestinal fistula formation after percutaneous catheter placement. A: Pre percutaneous catheter (PCD) computed tomography (CT)
showing walled off necrosis in left paracolic gutter (PCG) and subhepatic space; B: Axial CT showing pigtail in situ in the PCG collection (arrow); C: CT-PCD gram
(coronal section) showing communication of the collection with descending colon with contrast in the lumen (arrow); D: Colonoscopic image showing pigtail tip in the
colon lumen.
Initial catheter size is an important factor that may determine the success of PCD as well as other
outcomes but has been inadequately addressed in the literature. It is generally believed that liquefied
collections with a small amount of solid debris may be treated initially with small bore catheters ranging
from 8-12 F, and organized, solid looking collections be treated with larger bore catheters but high level
evidence is lacking[29,30]. Few retrospective studies and meta-analyses showed no significant difference
in outcome with respect to mean catheter size[30,31]. However, a recent study has reported a significant
reduction in ICU stay and number of re-admissions when patients were treated with an initial catheter
size of > 12 and overall mortality was not significantly lower in patients undergoing initial large bore
catheter drainage[11].
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6776 July 16, 2022 Volume 10 Issue 20
Figure 8 Rare and overlooked complications of percutaneous catheter placement. A: Clinical photograph of a patient with percutaneous catheter
drainage showing skin changes; B: Skin changes and erosions due to percutaneous catheter percutaneous catheter placement and pericatheter leak in another
patient; C: Abdominal Radiograph shows broken catheter (straight arrow) in right iliac fossa. Also note the other part of the same catheter (curved arrow); D: Catheter
tip fracture with shaft of catheter (curved arrow) and tip (straight arrow) seen separately on X-Ray and computed tomography.
TECHNICAL INNOVATIONS
Kissing catheter technique
This technique involves placement of two catheters side by side through the same puncture site into the
collection after serial dilatation of the tract[32]. The kissing catheters were deployed only when patients
failed to respond to serial upgradations of a single catheter or mean CT density of the collection was >
30 HU, and the purpose of the kissing catheters was to provide one catheter for flushing and another for
aspiration. Flushing, aspiration, and/or upsizing were done till there was no residual collection left.
With this technique, eight out of ten treated patients did not require a surgical necrosectomy[32].
Double lumen catheters
Liu et al[33] described a double catheter technique in which an inlet catheter for flushing and an
aspirator catheter for drainage were inserted inside a large aperture tube with multiple side holes. One
group of 15 patients underwent this double catheter placement followed by 1-2 wk of lavage, after
which patients underwent percutaneous flexible endoscopic debridement. The other group of 12
patients underwent standard PCD placement with open necrosectomy thereafter. It was found that the
occurrence of major complications and/or death was significantly lower in the double catheter group
than in the standard PCD group. There was a lower rate of occurrence of new onset OF and reduced
length of ICU stay in the double catheter group.
Another group evaluated the role of a novel dual-lumen flushable drainage catheter in evacuation of
complex fluid collections[34]. Two prototype catheters of 20 and 28 F size were created by incorporating
a customized infusion lumen within the wall of a large bore standard catheter and these were compared
with standard 20 and 28 F catheters in in vitro models. Drainage rate of double lumen catheters was
significantly superior to standard catheters in purulent, particulate, and haematoma models and
complete drainage was achieved with double lumen catheters in the purulent model. Based on the
promising results, these catheters may also improve outcomes in patients with necrotizing AP.
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6777 July 16, 2022 Volume 10 Issue 20
LAVAGE OF CATHETERS
Large volume lavage with normal saline
A randomized controlled trial compared patients undergoing lavage treatment (LT group) with
dependent drainage (DD group) with primary end points being reversal of pre-existing OF,
development of new onset OF, need for surgery, mortality, and hospital stay[35]. Lavage was initiated
within 24 h of PCD insertion in the LT group and it was done with warmed isotonic saline solution.
Initially, 250 mL was instilled through the catheter over 1-2 h and the catheter left on dependent
drainage for the rest of the day. In patients with lavage return ≥ 70% of infused volume, lavage volume
was gradually increased over 3-4 d and this fluid was infused slowly. Lavage was done for a period of 2
wk. The DD group did not undergo any lavage treatment and was left for standard drainage. It was
shown that lavage treatment resulted in a significant reversal of OF and reduction in acute physiology
and chronic health evaluation II scores as compared to the DD group. No difference was reported in the
development of new onset OF, catheter related complications, or number of catheters between the two
groups.
Local antibiotic instillation
Werge et al[36] retrospectively evaluated patients treated with endoscopic transmural drainage and
necrosectomy who underwent local instillation of antibiotics depending on microbial findings. Both
intravenous and local antibiotics did not show eradication of bacteria between the first and second
culture; however, local antibiotics were associated with eradication of microbes between the second and
third culture which was not seen with intravenous antibiotics[36]. Thus, local instillation of antibiotics
depending on microbial culture report can lead to early eradication of infection in MID. Although there
are no published studies reporting the use of local antibiotics through the percutaneous catheters, there
seems to be a potential role for local antibiotics to improve outcomes in patients undergoing PCD.
Instillation of necrolytic agents
Streptokinase: Streptokinase acts on the surface of the necrosum and causes fibrinolysis which leads to
its dissolution. This leads to better drainage of solid contents of the PFCs[37]. A retrospective study
demonstrated that streptokinase irrigation of the PFC through percutaneous catheters resulted in a
significantly higher sepsis reversal and reduced need for surgery in the streptokinase group as
compared to saline irrigation[37]. Two doses of streptokinase were used (50000 IU/150000IU diluted in
100 mL saline infused over 60 min) and higher dose resulted in lower rates of necrosectomy, bleeding,
and mortality.
Streptokinase vs hydrogen peroxide: Another study by the same group compared streptokinase
irrigation (50000 IU in 100 mL saline) with hydrogen peroxide irrigation (3% diluted in 100 mL saline)
[38]. Bleeding complications, need for surgery, mortality, and post-irrigation hospital stay were higher
in the hydrogen peroxide group than in the streptokinase group; however, the difference was not statist-
ically significant. Streptokinase, thus, appears to be safer compared with hydrogen peroxide.
ABDOMINAL PARACENTESIS DRAINAGE AS AN ADJUNCT TO PCD
Abdominal paracentesis drainage (APD) prior to PCD as part of the modified step-up approach or to
relieve increased intra-abdominal pressure has shown encouraging results in a few studies. One study
compared outcomes in patients managed with APD preceding PCD and with PCD alone and
demonstrated that the reduction of peripancreatic fluid collection by < 50% after APD alone was an
independent predictor of the subsequent need for PCD[33]. A similar study showed that the mortality in
the APD plus PCD group was significantly lower than that with PCD alone, and mean interval between
onset of disease to further intervention was also decreased in the first group[39]. Another prospective
cohort study demonstrated a significant reduction in the severity scores and laboratory variables in the
APD-PCD group. However, no relevant factors could be identified to predict the need of APD[40].
A prospective study evaluated the role of APD in infectious complications in MSAP and SAP and it
was seen that patients who underwent APD had significantly lesser infectious complications as well as
need for further PCD than patients with PCD alone[41]. No significant difference was seen in microbial
spectrum or mortality between the two groups. Wang et al[42] evaluated the role of APD in decreasing
the intra-abdominal pressure in patients with severe AP with sterile fluid collections. Patients were
divided into a sterile collection group, a secondary infection group, and a primary infection group and it
was seen that intra-abdominal hypertension was an independent risk factor for secondary infection, and
a significant reduction in intra-abdominal pressure following APD (> 6.5 mmHg) led to a lower
incidence of infection and better alleviation of OF[43]. A systematic review and meta-analysis evaluated
the efficacy and safety of APD in patients with AP, and the pooled results suggested that APD
significantly reduced the length of hospital stay and mortality of all causes during hospitalization. There
was no increase in infectious complications following APD[44]. Thus, early application of APD prior to
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6778 July 16, 2022 Volume 10 Issue 20
PCD can improve outcomes, reduce infective complications, and reduce intra-abdominal pressure in
patients with MSAP and SAP.
DUAL-MODALITY DRAINAGE
ED alone may not be adequate in treating deep collections and may not be feasible in extremely ill
patients. Similarly, PCD alone leads to patient discomfort and risk of external pancreatic fistula. Thus, a
combined drainage, called dual modality drainage (DMD), can be used to combine the advantages of
both these modalities (internal drainage of ED and drainage of deep collections by PCD) (Figure 6).
Irrigation of the collection with PCD as the ingress and internal drainage through the ED stent can result
in debridement of the majority of the solid necrosum[16]. The newer LAMS have a large bore which is
advantageous in draining solid component if irrigation and flushing are done using this technique. This
can result in early removal of PCD, which may prevent formation of cutaneous fistula[16,45]. Improved
outcomes were seen with addition of ED to PCD in a few studies[44,45]. One of these studies compared
DMD to standard PCD and it was seen that the DMD cohort had a shorter hospital stay, shorter time to
removal of PCD, fewer CT scans, and fewer endoscopic retrograde cholangiopancreatography
procedures as compared to standard PCD. Additionally, none of the patients required surgery in the
DMD group[45]. Another study comprising patients undergoing DMD demonstrated that none of the
patients required surgical necrosectomy, and all patients who had completed treatment had their
catheters removed, without any formation of pancreatocutaneous fistula[45].
FACTORS PREDICTING RESPONSE TO PCD
Success of PCD is defined as recovery of patients without need for surgery and resolution of OF[11,32,
46]. Multiple factors affect the success of PCD. These can be grouped into pre-PCD or post-PCD.
Pre-PCD predictors
One study reported a significant difference in the baseline values of C-reactive protein (CRP) and
interleukin (IL)-6 between the PCD success and PCD failure groups, where resolution of OF, sepsis, and
pressure symptoms was defined as success of PCD[46]. The mean baseline CRP values in the PCD
success and failure groups were 146.48 ± 111.6 mg/L vs 189.10 ± 55.5 mg/L, respectively, and for IL-6,
they were 166.09 ± 51.21 pg/mL vs 215.81 ± 52.40 pg/mL. Another study showed that pre-PCD CT
density of the necrotic collection was significantly lower in the PCD success group compared to the PCD
failure group[47]. Male sex, multiple OF, higher percentage of parenchymal necrosis, and heterogeneous
attenuation of the collection were associated with a poorer outcome in another study[48].
Post-PCD predictors
CRP, IL-6, and IL-10 were seen to significantly decrease 7 d after PCD insertion in the PCD success
group compared to the PCD failure group, and the percentage of decrease of IL-6 on day 3 and CRP on
day 7 correlated with the outcomes[46].
COMPLICATIONS OF PCD
Secondary infection of sterile necrosis or pseudocyst is a frequent complication and occurs in about 8%
of the patients[29]. Conversely, peritoneal spill of infected pancreatic necrosis can occur in transperi-
toneal PCD or through intestinal leakage[29]. Haemorrhage is usually self-limited and venous in origin.
Haemorrhage can occur within the pancreatic parenchyma, or inside the PFC or the gastrointestinal
tract depending on the site of involvement[7]. Haemorrhage into the GI tract may present with upper or
lower GI bleeding depending on etiology and the rate of haemorrhage. Bleeding into the peritoneal
cavity may lead to abdominal distension and haemodynamic instability, whereas haemorrhage into the
collection may not present with any outward signs except for haemodynamic instability. Sometimes, it
can be due to rupture of an arterial branch during access, or formation of pseudoaneurysm during PCD
insertion or LAMS placement[8,30,31]. These are usually managed by endovascular embolization.
Formation of external pancreato-cutaneous fistula is common and is defined as persistent measurable
drainage of clear pancreatic fluid (usually > 100 mL) through the percutaneous drain or the PCD tract
more than 3 wk after PCD insertion[12]. Incidence can vary between 5 to 35% according to different
studies[49-51]. In one study, these fistulae closed after a median period of 70 d[52]. In case of non-
resolution, pancreatic duct stenting is indicated[12]. Internal gastrointestinal fistulae can also develop
post PCD and they may be spontaneous, or caused by erosion of catheter into bowel wall or by
iatrogenic injury of the wall during catheter placement (Figure 7). The most common site of these
fistulae is the splenic flexure of the colon[17,53]. Management of GI fistulae depends on their location.
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6779 July 16, 2022 Volume 10 Issue 20
Figure 9 Direct endoscopic necrosectomy. A: Endoscopic images showing large amount of necrotic debris within the collection; B: Snare placed into the
necrotic collection using the endoscopic route; C: Partial removal of necrotic debris using snare; D: Dark necrotic residual collection seen with snare in situ.
Figure 10 Factors influencing success of percutaneous catheter. PCD: Percutaneous catheter drainage; APD: Abdominal paracentesis drainage; NS:
Normal saline; STK: Streptokinase.
Upper GI fistulae close spontaneously over time, whereas colonic fistula may be treated conservatively
with continuous PCD drainage in stable patients. However, if GI fistulisation is associated with frank
haemorrhage or sepsis, surgical management may be required.
Catheter displacement, blockage, and peri-catheter leak are common but under-reported. Depending
on the patients’ clinical status and presence of residual collection, these complications are managed by
removal, re-insertion, or upgradation of the catheter. Peri-catheter leak and sutures and dressing can
lead to skin erosion and bleeding (Figure 8A and B). Skin care thus becomes necessary in these patients.
Very rarely, the catheter tip may get fractured and remain within the necrotic cavity (Figure 8C and D).
OVERVIEW OF NECROSECTOMY
Necrosectomy can be endoscopic, MIS, laparoscopic, or open surgical. Step-up approach is used in both
endoscopic and percutaneous MIS techniques with a randomized controlled trial showing no difference
in mortality or complication rate between the two[10]. Endoscopic debridement consists of direct
endoscopic necrosectomy (DEN) or transpapillary drainage (TPD)[18]. DEN involves debridement of
necrotic tissue by passing an endoscope into the cavity, which can be done with fluid irrigation, or by
snares and baskets (Figure 9)[6,16,18]. TPD involves placement of pancreatic ductal stents in cases with
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6780 July 16, 2022 Volume 10 Issue 20
small collections (< 6 cm) communicating with the pancreatic duct[18].
Percutaneous minimally invasive techniques include percutaneous EN (PEN) which involves
insertion of endoscope along the PCD tract and debridement by snares and baskets; and video assisted
retroperitoneal debridement (VARD) which involves insertion of a zero-degree videoscope and
debridement. Both these techniques require PCD insertion through the left lateral position via the
retroperitoneal access route. Complete debridement is not the aim, and only loose necrosum is removed
[6,16,54]. However, VARD is associated with formation of a significant number of pancreatic fistulae.
Laparoscopic debridement can also be done which allows access to all abdominal compartments and
successful single session debridement is feasible in most patients[16].
Open surgical necrosectomy was the standard of care before the advent of MIS techniques. However,
due to its high morbidity, mortality, and complication rate, it has been superseded by minimally
invasive techniques[16]. These days, open surgical necrosectomy is reserved for patients who do not
respond to MIS or those who have an emergency indication for open surgery, which includes
abdominal compartment syndrome, perforation of hollow viscus, ischemic bowel infarction, or
uncontrolled haemorrhage which is not amenable for endovascular embolization[12].
CONCLUSION
PFC represent important complications of AP. Despite the increasing utilization of endoscopic and
minimally invasive surgical techniques, interventional radiologists and PCD remain integral to the
management of patients with PFC. They must be aware of the evolving indications and complementary
role of PCD, ED, and MIS and factors influencing success of PCD (Figure 10).
FOOTNOTES
Author contributions: Bansal A and Gupta P acquired the data, designed the outline of the paper, performed the
writing, and did the major revisions; Singh AK, Shah J, Samanta J, Mandavdhare HS, Sharma V, Sinha SK, Dutta U,
Sandhu MS, and Kochhar R contributed to data acquisition as well as to writing; all authors have read and approved
the final manuscript.
Conflict-of-interest statement: There is no conflict of interest associated with any of the senior author or other
coauthors contributed their efforts in this manuscript.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by
external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-
NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license
their derivative works on different terms, provided the original work is properly cited and the use is non-
commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Country/Territory of origin: India
ORCID number: Akash Bansal 0000-0003-1180-3098; Pankaj Gupta 0000-0003-3914-3757; Anupam K Singh 0000-0002-7610-
1807; Jimil Shah 0000-0001-5773-912X; Jayanta Samanta 0000-0002-9277-5086; Harshal S Mandavdhare 0000-0001-8020-
9848; Vishal Sharma 0000-0003-2472-3409; Saroj Kant Sinha 0000-0001-8088-9935; Usha Dutta 0000-0002-9435-3557;
Manavjit Singh Sandhu 0000-0001-6365-6291; Rakesh Kochhar 0000-0002-4077-6474.
S-Editor: Guo XR
L-Editor: Wang TQ
P-Editor: Yu HG
REFERENCES
Foster BR, Jensen KK, Bakis G, Shaaban AM, Coakley FV. Revised Atlanta Classification for Acute Pancreatitis: A
Pictorial Essay. Radiographics 2016; 36: 675-687 [PMID: 27163588 DOI: 10.1148/rg.2016150097]
1
Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis
Classification Working Group. Classification of acute pancreatitis--2012: revision of the Atlanta classification and
definitions by international consensus. Gut 2013; 62: 102-111 [PMID: 23100216 DOI: 10.1136/gutjnl-2012-302779]
2
Trikudanathan G, Tawfik P, Amateau SK, Munigala S, Arain M, Attam R, Beilman G, Flanagan S, Freeman ML, Mallery
S. Early (<4 Weeks) Versus Standard (≥ 4 Weeks) Endoscopically Centered Step-Up Interventions for Necrotizing
Pancreatitis. Am J Gastroenterol 2018; 113: 1550-1558 [PMID: 30279466 DOI: 10.1038/s41395-018-0232-3]
3
Oblizajek N, Takahashi N, Agayeva S, Bazerbachi F, Chandrasekhara V, Levy M, Storm A, Baron T, Chari S, Gleeson
FC, Pearson R, Petersen BT, Vege SS, Lennon R, Topazian M, Abu Dayyeh BK. Outcomes of early endoscopic
4
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6781 July 16, 2022 Volume 10 Issue 20
intervention for pancreatic necrotic collections: a matched case-control study. Gastrointest Endosc 2020; 91: 1303-1309
[PMID: 31958461 DOI: 10.1016/j.gie.2020.01.017]
van Grinsven J, van Brunschot S, van Baal MC, Besselink MG, Fockens P, van Goor H, van Santvoort HC, Bollen TL;
Dutch Pancreatitis Study Group. Natural History of Gas Configurations and Encapsulation in Necrotic Collections During
Necrotizing Pancreatitis. J Gastrointest Surg 2018; 22: 1557-1564 [PMID: 29752684 DOI: 10.1007/s11605-018-3792-z]
5
Baron TH, DiMaio CJ, Wang AY, Morgan KA. American Gastroenterological Association Clinical Practice Update:
Management of Pancreatic Necrosis. Gastroenterology 2020; 158: 67-75.e1 [PMID: 31479658 DOI:
10.1053/j.gastro.2019.07.064]
6
Shyu JY, Sainani NI, Sahni VA, Chick JF, Chauhan NR, Conwell DL, Clancy TE, Banks PA, Silverman SG. Necrotizing
pancreatitis: diagnosis, imaging, and intervention. Radiographics 2014; 34: 1218-1239 [PMID: 25208277 DOI:
10.1148/rg.345130012]
7
Lee MJ, Wittich GR, Mueller PR. Percutaneous intervention in acute pancreatitis. Radiographics 1998; 18: 711-24;
discussion 728 [PMID: 9599393 DOI: 10.1148/radiographics.18.3.9599393]
8
van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, van Goor H, Schaapherder AF,
van Eijck CH, Bollen TL, van Ramshorst B, Nieuwenhuijs VB, Timmer R, Laméris JS, Kruyt PM, Manusama ER, van der
Harst E, van der Schelling GP, Karsten T, Hesselink EJ, van Laarhoven CJ, Rosman C, Bosscha K, de Wit RJ, Houdijk AP,
van Leeuwen MS, Buskens E, Gooszen HG; Dutch Pancreatitis Study Group. A step-up approach or open necrosectomy for
necrotizing pancreatitis. N Engl J Med 2010; 362: 1491-1502 [PMID: 20410514 DOI: 10.1056/NEJMoa0908821]
9
van Brunschot S, van Grinsven J, van Santvoort HC, Bakker OJ, Besselink MG, Boermeester MA, Bollen TL, Bosscha K,
Bouwense SA, Bruno MJ, Cappendijk VC, Consten EC, Dejong CH, van Eijck CH, Erkelens WG, van Goor H, van
Grevenstein WMU, Haveman JW, Hofker SH, Jansen JM, Laméris JS, van Lienden KP, Meijssen MA, Mulder CJ,
Nieuwenhuijs VB, Poley JW, Quispel R, de Ridder RJ, Römkens TE, Scheepers JJ, Schepers NJ, Schwartz MP, Seerden T,
Spanier BWM, Straathof JWA, Strijker M, Timmer R, Venneman NG, Vleggaar FP, Voermans RP, Witteman BJ, Gooszen
HG, Dijkgraaf MG, Fockens P; Dutch Pancreatitis Study Group. Endoscopic or surgical step-up approach for infected
necrotising pancreatitis: a multicentre randomised trial. Lancet 2018; 391: 51-58 [PMID: 29108721 DOI:
10.1016/S0140-6736(17)32404-2]
10
Gupta P, Bansal A, Samanta J, Mandavdhare H, Sharma V, Gupta V, Yadav TD, Dutta U, Kochhar R, Singh Sandhu M.
Larger bore percutaneous catheter in necrotic pancreatic fluid collection is associated with better outcomes. Eur Radiol
2021; 31: 3439-3446 [PMID: 33151396 DOI: 10.1007/s00330-020-07411-6]
11
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: 1994-2007.e3 [PMID:
30776347 DOI: 10.1053/j.gastro.2019.01.269]
12
van Baal MC, Bollen TL, Bakker OJ, van Goor H, Boermeester MA, Dejong CH, Gooszen HG, van der Harst E, van Eijck
CH, van Santvoort HC, Besselink MG; Dutch Pancreatitis Study Group. The role of routine fine-needle aspiration in the
diagnosis of infected necrotizing pancreatitis. Surgery 2014; 155: 442-448 [PMID: 24287142 DOI:
10.1016/j.surg.2013.10.001]
13
ASGE Standards of Practice Committee; Early DS, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, Evans JA,
Fanelli RD, Fisher DA, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF,
Saltzman JR, Sharaf RN, Shergill AK, Cash BD. Adverse events associated with EUS and EUS with FNA. Gastrointest
Endosc 2013; 77: 839-843 [PMID: 23684089 DOI: 10.1016/j.gie.2013.02.018]
14
van Grinsven J, van Brunschot S, Bakker OJ, Bollen TL, Boermeester MA, Bruno MJ, Dejong CH, Dijkgraaf MG, van
Eijck CH, Fockens P, van Goor H, Gooszen HG, Horvath KD, van Lienden KP, van Santvoort HC, Besselink MG; Dutch
Pancreatitis Study Group. Diagnostic strategy and timing of intervention in infected necrotizing pancreatitis: an
international expert survey and case vignette study. HPB (Oxford) 2016; 18: 49-56 [PMID: 26776851 DOI:
10.1016/j.hpb.2015.07.003]
15
Freeman ML, Werner J, van Santvoort HC, Baron TH, Besselink MG, Windsor JA, Horvath KD, vanSonnenberg E,
Bollen TL, Vege SS; International Multidisciplinary Panel of Speakers and Moderators. Interventions for necrotizing
pancreatitis: summary of a multidisciplinary consensus conference. Pancreas 2012; 41: 1176-1194 [PMID: 23086243 DOI:
10.1097/MPA.0b013e318269c660]
16
Jiang W, Tong Z, Yang D, Ke L, Shen X, Zhou J, Li G, Li W, Li J. Gastrointestinal Fistulas in Acute Pancreatitis With
Infected Pancreatic or Peripancreatic Necrosis: A 4-Year Single-Center Experience. Medicine (Baltimore) 2016; 95: e3318
[PMID: 27057908 DOI: 10.1097/MD.0000000000003318]
17
Nabi Z, Basha J, Reddy DN. Endoscopic management of pancreatic fluid collections-revisited. World J Gastroenterol
2017; 23: 2660-2672 [PMID: 28487603 DOI: 10.3748/wjg.v23.i15.2660]
18
Boxhoorn L, van Dijk SM, van Grinsven J, Verdonk RC, Boermeester MA, Bollen TL, Bouwense SAW, Bruno MJ,
Cappendijk VC, Dejong CHC, van Duijvendijk P, van Eijck CHJ, Fockens P, Francken MFG, van Goor H, Hadithi M,
Hallensleben NDL, Haveman JW, Jacobs MAJM, Jansen JM, Kop MPM, van Lienden KP, Manusama ER, Mieog JSD,
Molenaar IQ, Nieuwenhuijs VB, Poen AC, Poley JW, van de Poll M, Quispel R, Römkens TEH, Schwartz MP, Seerden
TC, Stommel MWJ, Straathof JWA, Timmerhuis HC, Venneman NG, Voermans RP, van de Vrie W, Witteman BJ,
Dijkgraaf MGW, van Santvoort HC, Besselink MG; Dutch Pancreatitis Study Group. Immediate versus Postponed
Intervention for Infected Necrotizing Pancreatitis. N Engl J Med 2021; 385: 1372-1381 [PMID: 34614330 DOI:
10.1056/NEJMoa2100826]
19
van Baal MC, van Santvoort HC, Bollen TL, Bakker OJ, Besselink MG, Gooszen HG; Dutch Pancreatitis Study Group.
Systematic review of percutaneous catheter drainage as primary treatment for necrotizing pancreatitis. Br J Surg 2011; 98:
18-27 [PMID: 21136562 DOI: 10.1002/bjs.7304]
20
Zhang Y, Yu WQ, Zhang J, Fu SQ, Fu QH, Liang TB. Efficacy of Early Percutaneous Catheter Drainage in Acute
Pancreatitis of Varying Severity Associated With Sterile Acute Inflammatory Pancreatic Fluid Collection. Pancreas 2020;
49: 1246-1254 [PMID: 33003087 DOI: 10.1097/MPA.0000000000001666]
21
Mukund A, Singla N, Bhatia V, Arora A, Patidar Y, Sarin SK. Safety and efficacy of early image-guided percutaneous 22
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6782 July 16, 2022 Volume 10 Issue 20
interventions in acute severe necrotizing pancreatitis: A single-center retrospective study. Indian J Gastroenterol 2019; 38:
480-487 [PMID: 32002829 DOI: 10.1007/s12664-019-00969-0]
Ke L, Dong X, Chen T, Doig GS, Li G, Ye B, Zhou J, Xiao X, Tong Z, Li W; Chinese Acute Pancreatitis Clinical Trials
Group (CAPCTG). Early on-demand drainage or standard management for acute pancreatitis patients with acute necrotic
collections and persistent organ failure: A pilot randomized controlled trial. J Hepatobiliary Pancreat Sci 2021; 28: 387-
396 [PMID: 33595879 DOI: 10.1002/jhbp.915]
23
Qu C, Zhang H, Chen T, Zhu Y, Feng Q, Guo F, Liu Z, Cao L, Yang J, Li G, Ye B, Zhou J, Ke L, Tong Z, Windsor J, Li
W; Chinese Acute Pancreatitis Clinical Trials Group(CAPCTG). Early on-demand drainage versus standard management
among acute necrotizing pancreatitis patients complicated by persistent organ failure: The protocol for an open-label multi-
center randomized controlled trial. Pancreatology 2020; 20: 1268-1274 [PMID: 32868182 DOI:
10.1016/j.pan.2020.08.012]
24
Mehta V, Kumar R, Parkash S, Singla S, Singh A, Chaudhary J, Bains H. Role of percutaneous catheter drainage as
primary treatment of necrotizing pancreatitis. Turk J Gastroenterol 2019; 30: 184-187 [PMID: 30457559 DOI:
10.5152/tjg.2018.17542]
25
Tyberg A, Karia K, Gabr M, Desai A, Doshi R, Gaidhane M, Sharaiha RZ, Kahaleh M. Management of pancreatic fluid
collections: A comprehensive review of the literature. World J Gastroenterol 2016; 22: 2256-2270 [PMID: 26900288 DOI:
10.3748/wjg.v22.i7.2256]
26
Szakó L, Mátrai P, Hegyi P, Pécsi D, Gyöngyi Z, Csupor D, Bajor J, Erőss B, Mikó A, Szakács Z, Dobszai D, Meczker Á,
Márta K, Rostás I, Vincze Á. Endoscopic and surgical drainage for pancreatic fluid collections are better than percutaneous
drainage: Meta-analysis. Pancreatology 2020; 20: 132-141 [PMID: 31706819 DOI: 10.1016/j.pan.2019.10.006]
27
Wroński M, Cebulski W, Karkocha D, Słodkowski M, Wysocki L, Jankowski M, Krasnodębski IW. Ultrasound-guided
percutaneous drainage of infected pancreatic necrosis. Surg Endosc 2013; 27: 2841-2848 [PMID: 23404151 DOI:
10.1007/s00464-013-2831-9]
28
Sharma V, Gorsi U, Gupta R, Rana SS. Percutaneous Interventions in Acute Necrotizing Pancreatitis. Trop Gastroenterol
2016; 37: 4-18 [PMID: 29668172 DOI: 10.7869/tg.314]
29
Ke L, Li J, Hu P, Wang L, Chen H, Zhu Y. Percutaneous Catheter Drainage in Infected Pancreatitis Necrosis: a Systematic
Review. Indian J Surg 2016; 78: 221-228 [PMID: 27358518 DOI: 10.1007/s12262-016-1495-9]
30
Bruennler T, Langgartner J, Lang S, Wrede CE, Klebl F, Zierhut S, Siebig S, Mandraka F, Rockmann F, Salzberger B,
Feuerbach S, Schoelmerich J, Hamer OW. Outcome of patients with acute, necrotizing pancreatitis requiring drainage-does
drainage size matter? World J Gastroenterol 2008; 14: 725-730 [PMID: 18205262 DOI: 10.3748/wjg.14.725]
31
Gupta P, Koshi S, Samanta J, Mandavdhare H, Sharma V, K Sinha S, Dutta U, Kochhar R. Kissing catheter technique for
percutaneous catheter drainage of necrotic pancreatic collections in acute pancreatitis. Exp Ther Med 2020; 20: 2311-2316
[PMID: 32765710 DOI: 10.3892/etm.2020.8897]
32
Liu WH, Wang T, Yan HT, Chen T, Xu C, Ye P, Zhang N, Liu ZC, Tang LJ. Predictors of percutaneous catheter drainage
(PCD) after abdominal paracentesis drainage (APD) in patients with moderately severe or severe acute pancreatitis along
with fluid collections. PLoS One 2015; 10: e0115348 [PMID: 25659143 DOI: 10.1371/journal.pone.0115348]
33
Roberts DG, Goudie MJ, Kim AJ, Kim H, Khademhosseini A, McWilliams JP. Novel Dual-Lumen Drainage Catheter to
Enhance the Active Evacuation of Complex Fluid Collections. J Vasc Interv Radiol 2021; 32: 882-889 [PMID: 33689833
DOI: 10.1016/j.jvir.2021.02.024]
34
Kohli P, Gupta V, Kochhar R, Yadav TD, Sinha SK, Lal A. Lavage through percutaneous catheter drains in severe acute
pancreatitis: Does it help? Pancreatology 2019; 19: 929-934 [PMID: 31521496 DOI: 10.1016/j.pan.2019.09.003]
35
Werge M, Novovic S, Roug S, Knudsen JD, Feldager E, Gluud LL, Schmidt PN. Evaluation of local instillation of
antibiotics in infected walled-off pancreatic necrosis. Pancreatology 2018; 18: 642-646 [PMID: 29958817 DOI:
10.1016/j.pan.2018.06.005]
36
Bhargava V, Gupta R, Vaswani P, Jha B, Rana SS, Gorsi U, Kang M. Streptokinase irrigation through a percutaneous
catheter helps decrease the need for necrosectomy and reduces mortality in necrotizing pancreatitis as part of a step-up
approach. Surgery 2021; 170: 1532-1537 [PMID: 34127302 DOI: 10.1016/j.surg.2021.05.028]
37
Bhargava MV, Rana SS, Gorsi U, Kang M, Gupta R. Assessing the Efficacy and Outcomes Following Irrigation with
Streptokinase Versus Hydrogen Peroxide in Necrotizing Pancreatitis: A Randomized Pilot Study. Dig Dis Sci 2021 [PMID:
34405362 DOI: 10.1007/s10620-021-07201-0]
38
Liu WH, Ren LN, Chen T, Liu LY, Jiang JH, Wang T, Xu C, Yan HT, Zheng XB, Song FQ, Tang LJ. Abdominal
paracentesis drainage ahead of percutaneous catheter drainage benefits patients attacked by acute pancreatitis with fluid
collections: a retrospective clinical cohort study. Crit Care Med 2015; 43: 109-119 [PMID: 25251762 DOI:
10.1097/CCM.0000000000000606]
39
Zerem E, Kunosić S, Zerem D, Boloban A, Zerem O, Zlomužica E. Benefits of abdominal paracentesis drainage performed
ahead of percutaneous catheter drainage as a modification of the step-up approach in acute pancreatitis with fluid
collections. Acta Gastroenterol Belg 2020; 83: 285-293 [PMID: 32603048]
40
Liu L, Yan H, Liu W, Cui J, Wang T, Dai R, Liang H, Luo H, Tang L. Abdominal Paracentesis Drainage Does Not
Increase Infection in Severe Acute Pancreatitis: A Prospective Study. J Clin Gastroenterol 2015; 49: 757-763 [PMID:
26053169 DOI: 10.1097/MCG.0000000000000358]
41
Wang T, Liu LY, Luo H, Dai RW, Liang HY, Chen T, Yan HT, Cui JF, Li NL, Yang W, Liu WH, Tang LJ. Intra-
Abdominal Pressure Reduction After Percutaneous Catheter Drainage Is a Protective Factor for Severe Pancreatitis Patients
With Sterile Fluid Collections. Pancreas 2016; 45: 127-133 [PMID: 26390416 DOI: 10.1097/MPA.0000000000000420]
42
Lu Z, Zhu X, Hua T, Zhang J, Xiao W, Jia D, Yang M. Efficacy and safety of abdominal paracentesis drainage on patients
with acute pancreatitis: a systematic review and meta-analysis. BMJ Open 2021; 11: e045031 [PMID: 34373293 DOI:
10.1136/bmjopen-2020-045031]
43
Gluck M, Ross A, Irani S, Lin O, Gan SI, Fotoohi M, Hauptmann E, Crane R, Siegal J, Robinson DH, Traverso LW,
Kozarek RA. Dual modality drainage for symptomatic walled-off pancreatic necrosis reduces length of hospitalization,
radiological procedures, and number of endoscopies compared to standard percutaneous drainage. J Gastrointest Surg
44
Bansal A et al. Drainage of pancreatic fluid collections
WJCC https://www.wjgnet.com 6783 July 16, 2022 Volume 10 Issue 20
2012; 16: 248-56; discussion 256 [PMID: 22125167 DOI: 10.1007/s11605-011-1759-4]
Ross AS, Irani S, Gan SI, Rocha F, Siegal J, Fotoohi M, Hauptmann E, Robinson D, Crane R, Kozarek R, Gluck M. Dual-
modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes. Gastrointest
Endosc 2014; 79: 929-935 [PMID: 24246792 DOI: 10.1016/j.gie.2013.10.014]
45
Mallick B, Tomer S, Arora SK, Lal A, Dhaka N, Samanta J, Sinha SK, Gupta V, Yadav TD, Kochhar R. Change in serum
levels of inflammatory markers reflects response of percutaneous catheter drainage in symptomatic fluid collections in
patients with acute pancreatitis. JGH Open 2019; 3: 295-301 [PMID: 31406922 DOI: 10.1002/jgh3.12158]
46
Guo Q, Li A, Hu W. Predictive factors for successful ultrasound-guided percutaneous drainage in necrotizing pancreatitis.
Surg Endosc 2016; 30: 2929-2934 [PMID: 26487212 DOI: 10.1007/s00464-015-4579-x]
47
Hollemans RA, Bollen TL, van Brunschot S, Bakker OJ, Ahmed Ali U, van Goor H, Boermeester MA, Gooszen HG,
Besselink MG, van Santvoort HC; Dutch Pancreatitis Study Group. Predicting Success of Catheter Drainage in Infected
Necrotizing Pancreatitis. Ann Surg 2016; 263: 787-792 [PMID: 25775071 DOI: 10.1097/SLA.0000000000001203]
48
Gomatos IP, Halloran CM, Ghaneh P, Raraty MG, Polydoros F, Evans JC, Smart HL, Yagati-Satchidanand R, Garry JM,
Whelan PA, Hughes FE, Sutton R, Neoptolemos JP. Outcomes From Minimal Access Retroperitoneal and Open Pancreatic
Necrosectomy in 394 Patients With Necrotizing Pancreatitis. Ann Surg 2016; 263: 992-1001 [PMID: 26501713 DOI:
10.1097/SLA.0000000000001407]
49
Horvath KD, Kao LS, Wherry KL, Pellegrini CA, Sinanan MN. A technique for laparoscopic-assisted percutaneous
drainage of infected pancreatic necrosis and pancreatic abscess. Surg Endosc 2001; 15: 1221-1225 [PMID: 11727105 DOI:
10.1007/s004640080166]
50
Raraty MG, Halloran CM, Dodd S, Ghaneh P, Connor S, Evans J, Sutton R, Neoptolemos JP. Minimal access
retroperitoneal pancreatic necrosectomy: improvement in morbidity and mortality with a less invasive approach. Ann Surg
2010; 251: 787-793 [PMID: 20395850 DOI: 10.1097/SLA.0b013e3181d96c53]
51
Bakker OJ, van Baal MC, van Santvoort HC, Besselink MG, Poley JW, Heisterkamp J, Bollen TL, Gooszen HG, van
Eijck CH; Dutch Pancreatitis Study Group. Endoscopic transpapillary stenting or conservative treatment for pancreatic
fistulas in necrotizing pancreatitis: multicenter series and literature review. Ann Surg 2011; 253: 961-967 [PMID: 21422914
DOI: 10.1097/SLA.0b013e318212e901]
52
Hua Z, Su Y, Huang X, Zhang K, Yin Z, Wang X, Liu P. Analysis of risk factors related to gastrointestinal fistula in
patients with severe acute pancreatitis: a retrospective study of 344 cases in a single Chinese center. BMC Gastroenterol
2017; 17: 29 [PMID: 28193160 DOI: 10.1186/s12876-017-0587-8]
53
van Santvoort HC, Besselink MG, Horvath KD, Sinanan MN, Bollen TL, van Ramshorst B, Gooszen HG; Dutch Acute
Pancreatis Study Group. Videoscopic assisted retroperitoneal debridement in infected necrotizing pancreatitis. HPB
(Oxford) 2007; 9: 156-159 [PMID: 18333133 DOI: 10.1080/13651820701225688]
54
