Algorithm for Peripancreatic Collection Drainage in Children
The management of peripancreatic collections in children should follow a step-up approach, starting with the least invasive methods and progressing to more invasive interventions only when necessary, with endoscopic ultrasound-guided drainage as the preferred first-line intervention for symptomatic collections.
Classification of Pancreatic Collections
- Pancreatic collections are classified according to the revised Atlanta classification based on the presence of necrosis and time since onset of pancreatitis 1
- Acute collections (within 4 weeks of pancreatitis onset):
- Acute peripancreatic fluid collections (non-necrotic)
- Acute necrotic collections (containing variable amounts of fluid and necrotic tissue) 2
- Chronic collections (after 4 weeks of pancreatitis onset):
Indications for Intervention
- Clinical deterioration with signs or strong suspicion of infected necrotizing pancreatitis 2
- After 4 weeks from disease onset:
- After 8 weeks from disease onset:
- Ongoing pain and/or discomfort 2
- Size alone is not an indication for drainage; under revised criteria, intervention should be based on symptoms and complications 2, 1
Step-Up Approach Algorithm
Step 1: Initial Assessment and Management
- Differentiate between simple pseudocyst and walled-off necrosis using EUS or MRI 3
- When infection is suspected, obtain cultures through CT-guided fine-needle aspiration 3
- Tailor antibiotic therapy based on culture results 3
- Initiate enteral feeding early to decrease risk of infected necrosis 3
Step 2: Minimally Invasive Drainage
Endoscopic ultrasound-guided transmural drainage (EUS-TD) is the preferred first-line approach for symptomatic collections in children 4, 5
Percutaneous catheter drainage (PCD) considerations:
- May be used for collections not amenable to endoscopic approach 1
- Appropriate for large, complex collections involving the pancreatic tail 2
- Typically requires prolonged drainage period compared to other abscesses 2
- Associated with higher rates of reintervention and longer hospital stays 2
- Limited success (14-32% cure rate) when used alone for necrotic collections 2, 1
Step 3: Advanced Interventions (if Step 2 fails)
- Endoscopic necrosectomy for infected necrosis not responding to drainage 6
- Minimally invasive surgical strategies:
- Open surgical intervention only when less invasive approaches fail 2
Timing of Interventions
- Postpone surgical interventions for more than 4 weeks after disease onset to reduce mortality 2
- Allow collections to become walled-off (typically after 4 weeks) before intervention 2
- For infected necrosis, percutaneous drainage as first-line treatment delays surgical intervention to a more favorable time 2
Special Considerations in Children
- Laparoscopic drainage has been successfully attempted in pediatric patients, though data is limited 2
- EUS-guided transmural drainage has been demonstrated as safe and effective in pediatric patients 4
- Evaluate main pancreatic duct status, as complete occlusion central to the pseudocyst may lead to failure of PCD 2
Pitfalls to Avoid
- Avoid early surgery (less than 4 weeks after onset) as it results in higher mortality 2
- Don't rely solely on size as criterion for intervention 2, 1
- Recognize that simple drainage procedures without debridement may predispose to infection when pancreatic necrosis is unrecognized 3
- Avoid needle aspiration for therapeutic purposes; it should be used primarily as a diagnostic tool 2
- Don't manage infected necrosis at centers without specialist expertise in endoscopic, radiologic, and surgical management 3