Figure 3. Endoscopic retrograde cholangiopancreatography for choledocholithiasis. (A) Endoscopic image of a biliary sphincterotomy
being performed at the major papilla with a sphincterotome. (B) Endoscopic image of a large common bile duct (CBD) stone following
balloon extraction. The stone is left in the CBD to pass on its own after removal.
Figure 4. 7.5-MHz endoscopic ultrasound image of a thick-walled
pancreatic pseudocyst in a patient with moderate to severe acute
fluid collections and/or pseudocysts do not require
interventions unless they become infected or cause
significant extrinsic compression of other organs.
The management of chronic fluid collections such
as pseudocysts is complex and controversial. In
general, small pseudocysts are treated via observation. Large cysts, cysts that become infected, or
cysts that compress the stomach or bowel (causing
gastric outlet obstruction) or the bile duct (causing
jaundice) are more likely to warrant drainage by
endoscopic, surgical, or interventional radiology
approaches.148,149 Surgical approaches can be performed in an open or laparoscopic manner. From
an endoscopic point of view, transmural (through
the stomach or the bowel wall) and transampullary
(through the pancreatic duct) approaches are available to drain pancreatic pseudocysts.
One Dutch multicenter, randomized controlled
trial demonstrated that in patients with infected
pancreatic necrosis, endoscopic or percutaneous
drainage of infected fluid collections followed by
minimally invasive retroperitoneal necrosectomy
achieved superior outcomes as compared to traditional open necrosectomy alone.150 Outcomes
were defined in terms of lower total costs, resources utilized, length of stay, long-term and major
complications, and death.
Acute pancreatitis remains a significant cause
of morbidity and mortality. Most patients with mild