Management of the later complications of severe acute pancreatitis - pseudocyst, abscess and fistula.

The first-line management of the later complications of severe acute pancreatitis has moved increasingly towards a non-operative approach. Asymptomatic pseudocysts may be safely observed while awaiting spontaneous resolution. Symptomatic, enlarging or complicated pseudocysts, particularly those with an immature wall, should be treated by percutaneous catheter drainage (PCD), reserving surgical drainage for treatment failures. Pancreatic abscesses, if coexisting necrosis can be confidently excluded, should respond to PCD or, if this fails, surgical external drainage. Pancreatic fistulas are rare and often respond to conservative measures. Endoscopically placed pancreatic ductal stents may allow the duct disruption to heal and avoid the need for surgical intervention.