Role of pancreatography in the endoscopic management of encapsulated pancreatic collections – review and new proposed classification

Table 1 Classifications of pancreatography findings

Ref.	Study object	Study objective	Descriptors	Classification	Practical implication
Dhir et al[23], 2018	EUS-drained WON	Pancreatography patters in WON and collection recurrence	-Duct disconnection; -Leaks	-Type I: Disconnection in the neck/body region, with a ductal leak at the proximal end; -Type II: Disconnected duct with a WON distal to the disconnection. It is not possible to ascertain the ductal communication of WON; -Type III: ductal leak without disconnection; -Type IV: Shows a noncommunicating WON, with no disconnection	Recurrence is higher in patters w/ disconnection (types I and II): -Type I: 5/35 patients (14.3%)–62.5% of recurrences; -Type II: 2/18 patients (11.1%) - 25% of recurrences; -Type III: 0/26 patients (0%) - 0% of recurrences; -Type IV: 1/8 patients (12.5%)–12.5% of recurrences
Mutignani et al[35], 2017	All pancreatic fistulas	Guide endoscopic approach	-Leakages; -Disruption (partial); -Disconnection (total)	-Type I: Leakages from small side brunches. IH: head | IB: body | IT: tail; -Type II: Leak in the MPD Open (IIO) or Close (IIC); -Type III: leaks after pancreatectomy; IIIP: Proximal pancreas (after distal pancreatectomy); IIID: Distal pancreas (after pancreaticoduodenectomy)	-IH and IB: Bridging OR NPD; -IT: Bridging OR cianoacrilate/fibrin/glue/polymer injection at pancreatic tail; -IIO: Bridging OR NPD OR transpapillary stent; -IIC: EUS transmural drain of collection from excluded gland OR EUS pancreaticogastrostomy OR Conversion to IIO and treat as IIO; -IIIP: Transpapillary stent; -IIID: Few endoscopic options. EUS transmural drainage OR nasojejunal drain at the level of dehiscence in continuous aspiration
Nealon et al[37], 2009	Pseudocyst due to pancreatitis1	Guide the best approach: endoscopic, interventional radiology or surgical intervention	-Normal2; -Stricture; -Chronic pancreatitis; -Occlusion; -Communication / no communication with collection	-Type I for normal ducts, IA: No communication, IB: With communication; -type II for duct strictures; IIA: no communication; IIB: with communication; -Type III for duct occlusion or disconnected duct syndrome; IIIA: no communication; IIIB: with communication; - Type IV for changes of chronic pancreatitis; IVA: no communication, IVB: with communication	-Type I: Endoscopic or percutaneous management; unlikely to require operation; -Type II: Endoscopic management depending on the magnitude and length of the stricture - transpapillary stents for selected ducts; -Type III and type IV: Surgical intervention exclusively
Nealon et al[41], 2002	Pseudocyst1 that underwent pancreatography by ERCP	Guide the best approach between percutaneous drainage or surgical intervention	-Normal2; -Strictures; -Complete cutoff; -Chronic pancreatitis;-MPD-pseudocyst communication or not	-Type I: normal duct/no communication with cyst; -Type II: normal duct with duct–cyst communication; -Type III: otherwise normal duct with stricture and no duct–cyst communication; -Type IV: otherwise normal duct with stricture and duct–cyst communication; -Type V: otherwise normal duct with complete cut-off; -Type VI: chronic pancreatitis, no duct–cyst communication; -Type VII: chronic pancreatitis with duct–cyst communication	-Type I: consider percutaneous drainage (PD); -Type II: avoid PD; -Type III: consider PD treatment; -Type IV: surgery (avoid PD); -Type V: surgery (avoid PD); -Type VI: surgery (avoid PD); -Type VII: surgery (avoid PD)
Nordback et al[7], 1988	Pseudocyst1 that underwent pancreatography by ERCP	Guide the best approach	-Stenosis; -Pseudocyst opens to the duct; -Pseudocyst is filled	-Type I: MPD is imaged up to the end without much stenosis, Pseudocyst may (Type IA) or may not (IB) be filled, but is further away from the main pancreatic duct; -Type II: no main duct stenosis and pseudocyst opens to the duct; -Type III: stenosis of the main pancreatic duct, + filling of the pseudocyst behind the stenosis (IIIA), or not (IIIB)	Type I: PD is a good option; Type II: expectant management for 12 wk, if persistent: Internal drainage (PD, endoscopically, surgery); Type III: Internal drainage (external drainage contraindicated); caudal resection

¹Pseudocyst before Revised Atlanta Classification could involve heterogeneous types of collections.

²“Normal duct” means duct without chronic pancreatitis changes. EUS: Endoscopic ultrasound; WON: Walled-off Necrosis; MPD: Main pancreatic duct; PD: Percutaneous drainage; NPD: Nasopancreatic drain.

Table 2 Lera-Proença new proposed classification for endoscopic pancreatography findings

Types	Finding	Endoscopic approaches
Type I	Normal MPD	No additional therapy
Type II	Stricture	Consider pancreatic stent
Type III	Partial disruption (MPD contrasts beyond disruption point)	Pancreatic stent bridging the rupture
Type IV	Complete disruption (MPD does not contrast beyond disruption point), A: With contrast extravasation; B: Without contrast extravasation and abrupt cut-off	CT or MRI to confirm or rule out DPDS; Consider long-term transmural indwelling plastic stents

MPD: Main pancreatic duct, CT: Computerized tomography; MRI: Magnetic resonance imaging; DPDS: Disconnected pancreatic duct syndrome.

Table 3 Comparation between pancreatography classifications

Ref.	Study modality	Guide endoscopic approach?	Category for partial MPD disruption?	Diagnosis or suspicion of DPDS?
Proença, 2020	ERCP	Yes	Yes	Yes
Dhir et al[23], 2018	ERCP + MRCP	No	Yes	Yes
Mutignani et al[35], 2017	Not specified	Yes	No	No
Nealon et al[37], 2009	ERCP	No	No	No
Nordback et al[7], 1988	ERCP	No	No	No

ERCP: Endoscopic retrograde cholangiopancreatography; MRCP: Magnetic resonance cholangiopancreatography; MPD: Main pancreatic duct; DPDS: Disconnected Pancreatic Duct Syndrome.