In the setting of WOPN, the collection should be concomitantly treated with percutaneous drainage or endoscopic necrosectomy to prevent infection of the complex collection. The first description of transmural drainage for DDS demonstrated successful endoscopic treatment in 12 of 13 patients with DDS.[38] However, subsequent series have shown more mixed results. Over a seven-year period, selleck chemicals Pelaez-Luna et al. treated 31 patients with DDS with five patients going straight to surgery and 26 undergoing endoscopic treatment. Of the patients undergoing endoscopic treatment, 19 had good long-term

success while seven subsequently required surgery.[2] Varadarajulu et al. also described their experience with 33 patients with DDS. In their series, eight patients underwent surgery while 22 were successfully treated with transmural drainage with prolonged stenting. No patients experienced recurrent fluid collections despite three having spontaneous passage of stents after more than 100 days of follow-up.[58] Our group has recently described a combined endoscopic AG-014699 concentration and percutaneous treatment approach for WOPN and DDS.[51, 60, 62] Our prior experience treating WOPN with percutaneous drains alone demonstrated that up to one third of the patients developed external fistulas secondary to DDS with the inability to subsequently remove the drains. Therefore, we developed a new selleck technique wherein

we place transmural stents in addition to percutaneous drains for the treatment of WOPN (Fig. 2). Transmural stents are left in place indefinitely for patients with DDS. With this new technique, we have avoided cutaneous fistulas and greatly reduced the need for surgery for DDS. We have now treated more than 100 patients with WOPN with this technique with < 1% death related to pancreatitis and < 5 % requiring surgery. Interventional radiologists can offer other minimally invasive, surgery-sparing treatments for DDS. Cyanoacrylate or other glues has been described as a treatment for DDS with an

external pancreatic fistula.[63, 64] In this technique, a guidewire is advanced into the main pancreatic duct within the isolated segment of the pancreas. Subsequently, a microcatheter is advanced over the wire and glue is then injected to completely fill the pancreatic duct and all of its side branches within this section of the pancreas. This works best with a short, 3–4-cm segment of disconnected pancreas and is associated with mild procedural pancreatitis in 50% of patients. Our group has recently described a combined IR and endoscopic treatment for DDS and external pancreatic fistulas.[52] In this technique, initially a radiologist will pass a TIPS needle into the fistula tract. Using fluoroscopic and endoscopic guidance, this needle is then passed through the gastric wall into the stomach lumen.