Complicated pancreatic disease management—radiologist/interventionist batting cleanup?

Abstract

The long term results of various interventional procedures used in the treatment of patients with chronic pancreatic fistulas or severe pancreatic pain syndrome, after failure of both surgery and endoscopic catheterization, are described. Five patients were divided into two groups. Group 1 contained three patients with recurrent severe abdominal pain with superimposed episodes of acute pancreatitis. Two patients had undergone prior Whipple procedures but remained symptomatic. The third had a 6-yr history of alcoholic pancreatitis. All three had failed selective pancreatic endoscopy because of a proximal pancreatic duct stricture. The pancreatic duct was dilated to between 7 and 10 mm by CT or ultrasound imaging. Group 2 patients had pancreaticocutaneous fistulas that developed after surgical and percutaneous pseudocyst drainage. Both patients’ fistulas had been unresponsive to therapy with somatostatin analogues, and had been controlled by means of percutaneous drains. Patients were treated under either general anesthesia (two patients, patient preference) or conscious sedation. Each received preprocedure antibiotics and had normal coagulation profiles. Oral contrast was given to opacify the colon the night before the procedure. Ultrasound or fluoroscopic guidance was used to puncture the pancreatic duct, either directly or through the stomach (after placement of T fasteners). The procedures were then individualized to fit the particular pathology and anatomical situation. At least one procedure required endoscopic assistance (rendezvous procedure) for guidewire stabilization to deliver an angioplasty catheter across a pancreatic duct stricture. The criteria for successful treatment included partial or complete relief of abdominal pain, with normalization of pancreatic duct caliber in group 1 and cure of the pancreatic fistulas in group 2 without recurrent episodes of pancreatitis. All three patients in group 1 had prompt relief of abdominal pain after placement of percutaneous pancreatic duct drains. All had return to normal caliber of the pancreatic duct by imaging. One patient had a recurrent episode of abdominal pain after drain removal, but this was found to be due to a ureteral stricture. The details of the procedures for treating the fistulas have been previously reported (1). Cope and colleagues’ report assesses long term efficacy of these interventions. Both patients with fistulas were cured out to 5-yr follow-up after removal of their drains. None of these percutaneous procedures showed early complications such as leakage of pancreatic juice, sepsis, hemorrhage, or acute pancreatitis, as determined symptomatically by hematological screening and abdominal imaging. The authors conclude that percutaneous pancreatic duct drainage and stent placement is safe in selected cases. It is particularly useful when endoscopic stent placement is unsuccessful and surgery too risky. They also suggest several other situations in which this technique may be beneficial.