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. Topics covered Four-week wall maturation and drainage timing Pseudocyst versus walled-off necrosis Pseudoaneurysm check before puncture Step-up drainage and stent caliber LAMS dwell time and complications LAMS occlusion and tract bleeding failure modes Cyst fluid analysis parallel Direct endoscopic necrosectomy and the carbon dioxide rule Key decisions Wait 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. Review 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. Match 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. Drain 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. For a bleeding LAMS tract, embolize the pseudoaneurysm before removing the stent, since the LAMS may be tamponading the source; for an occluded LAMS, clear it and place double-pigtail plastic stents through it. Analyze an indeterminate tail cyst by EUS-guided aspiration: CEA above one hundred ninety-two or glucose below fifty favors mucinous, while high amylase indicates ductal communication. Use mandatory carbon dioxide insufflation and avoid forceful flushing during necrosectomy, because air can enter venous or peritoneal communications and cause air embolism, and debride a portion at a time across two to four sessions. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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“What did the council decide on item 42?” — answered with the speaker and the moment.

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