{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 28, Ep 6 of 7: Fluid Collections and Necrosectomy","html":"","width":"100%","height":180,"duration":631,"description":"Episode six takes the pancreatitis spectrum to its end: the collections the gland leaves behind. Timing runs on wall-maturation logic, waiting about four weeks for a rind strong enough to hold a transmural anastomosis, and the contents decide everything downstream, since a pseudocyst and walled-off necrosis need different stents and different follow-through. Before any puncture you image for a pseudoaneurysm and embolize it first, because needling a shared wall can cause uncontrolled hemorrhage. Drainage is a step-up, transmural first and necrosectomy only when the cavity will not empty, and two failure modes both turn on sequence. Necrosectomy itself carries one non-negotiable safety rule: carbon dioxide insufflation, because air can embolize.\n \nTopics covered\n\nFour-week wall maturation and drainage timing\nPseudocyst versus walled-off necrosis\nPseudoaneurysm check before puncture\nStep-up drainage and stent caliber\nLAMS dwell time and complications\nLAMS occlusion and tract bleeding failure modes\nCyst fluid analysis parallel\nDirect endoscopic necrosectomy and the carbon dioxide rule\n \n \nKey decisions\n\nWait about four weeks before draining a symptomatic collection so the inflammatory rind matures into a wall strong enough to hold a transmural anastomosis without leaking.\nReview the CT angiogram for a pseudoaneurysm before puncturing; when present, have interventional radiology embolize it first, because needling into or near it can cause uncontrolled hemorrhage.\nMatch stent caliber to contents: a ten millimeter LAMS or double-pigtail plastic stents for thin pseudocyst fluid, and a fifteen or twenty millimeter LAMS for walled-off necrosis so the endoscope can pass for necrosectomy.\nDrain transmurally first and escalate to necrosectomy only when the response is inadequate (persistent fever, leukocytosis, or solid debris), because the endoscopic route avoids the peritoneal wound complications of surgery.\nFor a bleeding LAMS tract, embolize the pseudoaneurysm before...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}