EUS-Guided Rendezvous and Tractogastrostomy: A Novel Technique for Disconnected Pancreatic Duct Syndrome with External Pancreatic Fistula

Background and study aims External pancreatic fistula in association with disconnected pancreatic duct syndrome is a common sequelae of the percutaneous step-up approach for infected pancreatic necrosis and is associated with significant morbidity. The present study aimed to report the initial outcome of a novel technique of two-scope guided tractogastrostomy for management of this condition. Patients and methods The present study was a retrospective analysis of data from patients with external pancreatic fistula and disconnected pancreatic duct syndrome, who underwent two-scope-guided tractogastrostomy. All the patients had a 24F or larger drain placed in the left retroperitoneum. Transgastric echo endoscopy and sinus tract endoscopy were performed simultaneously to place a stent between the gastric lumen and the sinus tract. Technical success was defined as placement of the stent between the tract and the stomach. Clinical success was defined as successful removal of the percutaneous drain without the occurrence of pancreatic fluid collection, ascites, external fistula, or another intervention 12 weeks after the procedure. Results Three patients underwent two scope-guided tractogastrostomy. Technical and clinical success were achieved in all the patients. No procedure-related side effects or recurrence occurred in any of the patients. Conclusions Two-scope-guided tractogastrostomy for treatment of external pancreatic fistula due to disconnected pancreatic duct syndrome is a feasible technique and can be further evaluated.

Octreotide was studied in the treatment of pure external pancreatic fistulas. Eighteen cases (12 males, 6 females) were prospectively observed. Six patients (four after radical surgery for periampullary cancer, one endocrine tumor enucleation and one pancreojejunostomy in chronic pancreatitis) were treated as outpatients with octreotide alone because of low basal fistula output (mean+/-SD: 96.6+/-27.4 cc/24 h). Twelve (five radical surgery for cancer, five surgery for severe pancreatitis, one enucleation and one pancreojejunostomy) were treated as inpatients with octreotide plus total parenteral nutrition because of the high output (mean+/-SD: 448.4+/-248.2 cc/24 h). Ten of the 12 high-output fistulas healed in 27.8+/-27.7 days, whereas all low-output fistulas healed in 12.1+/-6.6 days. Octreotide appears useful in the treatment of external pancreatic fistulas. For optimal results to be achieved, there must be no local infection and no mechanical or anatomical obstacles to the free flow of juice.

Transpapillary drainage of the main pancreatic duct (MPD) has been proposed for the treatment of external pancreatic fistulas (EPF) but may not suffice to treat complex cases. The aim of the present study was to explore the efficacy of various endoscopic or combined percutaneous and endoscopic techniques in the treatment of EPFs. Sixteen patients presenting with EPFs were treated in our department. The techniques applied and patients' clinical outcome are described. All but three patients underwent transpapillary MPD drainage by pancreatic sphincterotomy (N = 13). Additional endoscopic procedures performed were: (a) pancreatic fluid collection (PFC) drainage (N = 5), (b) transmural drainage between the fistula path and the gastrointestinal (GI) tract (N = 5), and (c) endoscopic ultrasound (EUS)-guided pancreaticoduodenostomy because of complete pancreatic duct rupture (N = 1). Fistula closure was achieved in all patients except one, who required surgery. During a median follow-up period of 18 months (range 6-52) three patients had fistula recurrence, and two, PFC recurrence. Both conditions were cured successfully by repeated endoscopic therapy. All recurrences occurred within 3 months of initial successful treatment. Combined endoscopic and percutaneous treatment appears to be safe and effective for the management of complex cases of EPFs.

The Endocrine and Pancreatic Unit at the University of Verona, Italy

Prior to the advent of somatostatin conservative therapy for pancreatic fistulas, treatment included intravenous nutritional therapy with nothing per mouth and therapeutic agents to diminish pancreatic secretions. None of these modalities were uniformly successful. A prospective study to evaluate the efficacy of a long-acting somatostatin analogue (Sandostatin) was carried out. 18 patients-10 with pancreatic ascites and 8 with external pancreatic fistulas-were treated. The ascites resolved in 9 of 10 patients in a mean period of 22 days (+/- 3 days). The external fistulas were all high output fistulas and resolved in 7 of 8 patients. Mean period for closure was 23 days. There were no side effects associated with Sandostatin. Sandostatin has made a major impact on the conservative treatment of pancreatic ascites and is an important adjunct to the management of external pancreatic fistulas. It is emphasised however that surgery may be required for the underlying pancreatic disease. In this regard close surveillance of these patients is necessary.

Management of External Pancreatic Fistulas. Outcomes of Endoscopic Treatment in Single Endoscopy Center

To evaluate the safety and feasibility of binding fistulojejunostomy, a new operative procedure, in the treatment of external pancreatic fistula. Eight patients suffering from external pancreatic fistula, 4 males and 4 females, aged 49 (22 approximately 69), underwent binding fistulojejunostomy: 2 cm-length of fistula was isolated and a tube was inserted therein, the jejunum was transected and the distant cut end was everted for the length of 3 cm, the mucosa of the everted jejunum was destroyed with carbolic acid, the everted mucosa of jejunum and the fistula were brought together and sutured with silk, the everted jejunum was then turned back to wrap over the fistula, a silk tie was lopped around the entire circumference of the anastomosis, and lastly, the tube was led out of the abdominal wall. all 8 patients recovered smoothly without pancreatic leakage and other complications. Binding fistulojejunostomy is safe and effective for the treatment of external pancreatic fistula.

Endoscopic pancreatic stent insertion for treatment of pseudocyst after distal pancreatectomy

The aim of this study was to describe catheterization techniques and report the results of percutaneous drainage of external pancreatic fistulas. Twenty patients with external pancreatic fistulas in whom medical therapy had failed, were referred for radiologically guided treatment. Fifteen patients had postoperative and five primary fistulas. Sixteen were high-output fistulas (H-OF) and four were low-output fistulas (L-OF). All patients were treated percutaneously. Percutaneous catheter drainage was successful in 16 of 20 patients (80 %). The fistula healed in 13 of 15 postoperative cases (86.6 %) and in three of five primary fistulas (60 %). Treatment was successful in 14 of 16 patients (87.5 %) with H-OF and in two of four patients with L-OF. Percutaneous catheterization of the pancreatic ducts was successful in eight of 20 patients (40 %); seven of these patients were cured. Catheterization was not achieved in 12 patients and treatment failed in three (25 %). Conservative treatment of external pancreatic fistulas with percutaneous catheter-directed drainage is thus a reasonable alternative to surgery, particularly in patients with H-OF.

Abstract. Introduction. External post-necrotic pancreatic fistulas can persist for months, worsening the quality of the patient’s life. Conservative and minimally invasive treatment methods are priorities for this pathology, with the primary focus on diagnosing and correcting intraductal hypertension. Aim. To present clinical observations on the minimally invasive elimination of external pancreatic fistulas resulting from necrotizing pancreatitis. Materials and Methods. We analyzed cases of 6 patients over 3 years with necrotic forms of acute pancreatitis that developed complications, such as persistent external pancreatic fistulas. After having verified the fistula and corrected intraductal hypertension, we performed sclerotherapy on these external fistulas. This article also describes the first one of these clinical cases. Results and Discussions. In all six cases, we observed the rapid closure of chronic post-necrotic pancreatic fistulas and maintenance of the achieved effect over more than a year of follow-up. Conclusions. Experience of Russian and foreign surgery colleagues shows the priority of using minimally invasive techniques in treating most complications of necrotizing pancreatitis, particularly external pancreatic fistulas. Extensive surgical interventions in such patients generally carry high risks. We were the first to apply sclerotherapy using aethoxysklerol for this complication; the successful experience suggests its further application, alone or in combination with other minimally invasive techniques.

Peripancreatic fluid collections (PFCs) occur in up to 30 % of patients following partial pancreatic resections. Traditionally, postoperative PFCs are managed via percutaneous drainage (PD). EUS-guided transgastric drainage has been shown to be effective for the management of PFCs secondary to acute pancreatitis. However, there are limited data on the use of EUS-guided drainage (EUSD) for the management of postoperative PFCs. To compare the safety and efficacy of PD versus EUSD of PFCs in patients who have undergone partial pancreatic resections. Retrospective analysis of patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy at MSKCC between January 2008 and December 2010. Patients were identified using an electronic medical records query in addition to a prospectively maintained pancreatic surgery complications database. Single, academic, tertiary referral center. Twenty-three patients with symptomatic PFCs following pancreatic enucleation or distal pancreatectomy were retrospectively identified. CT-guided PD versus endoscopic ultrasound-guided drainage (EUSD) MAIN OUTCOME MEASURES: Outcomes included technical success, clinical success, number of interventions, and complications. Technical success was defined as successful localization of the PFC by fine-needle aspiration and placement of a drainage catheter or stent. Clinical success was defined as radiographic resolution of the PFC and removal of the drain or stent, without the need for an alternative drainage procedure or surgery. PD was initially performed in 14 patients and EUSD initially in 9 patients. Three patients with initial PD had recurrence of PFC after removal of the external drain and underwent subsequent EUSD. The mean size of the fluid collections was 10.0 cm in the PD group and 8.9 cm in the EUSD group. Technical success was achieved in all patients in both groups. Clinical success was achieved in 11 of 14 (79 %) patients in the PD group compared with 11 of 11 (100 %) in the EUSD group, with one patient in the EUSD group lost to follow-up. One patient with initial PD required two additional percutaneous procedures before complete PFC resolution. Five EUSD patients required repeat endoscopy for stent revision or necrosectomy. The median number of interventions was two [range 1-5] in the PD group and two [range 1-5] in the EUSD group. The median number of days the drainage catheters were in place was 44.5 [range 2-87] in the PD group versus 57 [range 32-217] in the EUSD group. There were no procedure-related complications in either group. Adverse events in the PD group included splenic artery stump bleeding, pleural effusion, cysto-colonic and cysto-cutaneous fistulae, and persistent catheter site pain. One patient in the EUSD group developed a small-bowel obstruction and bleeding gastric ulcer. Retrospective, nonrandomized study and small numbers. EUSD of postoperative PFCs appears to be safe and technically feasible. This technique appears to be as successful as PD for the management of PFCs with the advantage of not requiring an external drainage apparatus and should be considered as a therapeutic option in this group of patients. Further evaluation, with analysis of cost and quality of life, should be considered in a prospective, randomized trial.

Walled-off pancreatic necrosis resulting from severe necrotizing pancreatitis often leads to complications, including disconnected pancreatic duct syndrome (DPDS) and the subsequent development of external pancreatic fistulas (EPFs). This study aimed to evaluate the long-term outcome of rendezvous internalization treatment for EPF associated with DPDS. A retrospective review of 40 patients with EPFs secondary to DPDS who underwent rendezvous treatment between October 2008 and October 2023 was conducted. Three techniques were utilized: outside-in (n = 18), inside-out (n = 19), and pancreatic duct bridging (n = 3). Primary outcomes included the rate of surgery post-treatment, while secondary outcomes encompassed recurrence of peripancreatic fluid collection (PFC) or EPF. The mean age of patients was 54.6years, with 67.5% being male. Gallstones (37.5%) and alcohol (25.0%) were the leading etiologies. The median time from pancreatitis onset to the procedure was 216days. All patients achieved EPF closure, with a median closure time of 20days. Procedure-related complications included post-procedural acute pancreatitis (12.5%) and minor bleeding (7.5%), with no perforations or mortality. During a median follow-up of 53.5months, recurrence of EPF occurred in three patients (7.5%), with two requiring surgery (5.0%). Recurrence of PFC (22.5%) and acute pancreatitis (17.5%) were also observed. New-onset diabetes mellitus occurred in 50% of patients. Rendezvous internalization treatments are highly effective for EPFs associated with DPDS, achieving high closure rates and low recurrence. These findings underscore their potential to reduce surgical necessity. Prospective studies are warranted to optimize strategies for these challenging cases.

FIGURES 69–74. Paradelia intersecta, male. 69, 70. Sternite V, lateral and ventral views. 71, 72. Hypopygium, caudal and lateral views. 73. Pre- and postgonites, lateral view. 74. Phallus, lateral view. Same scale for 69, 70 and 71–74 respectively.

The present paper describes clinical observation of successful treatment of a patient with chronic calcifying pancreatitis complicated by an external pancreatic fistula. Abdominal surgery after laparotomy and cholecystectomy had to be limited to bursoomentostomy due to the bleeding tissues and severe blood loss. Combined endoscopic intervention through the external pancreatic fistula was used for the treatment. The performed interventions included stone extraction in Wirsung’s duct, dilation and stenting of the distal stricture of the pancreatic duct. The fistula closed, a pain-free period lasted for 3 years. Similar transfistula interventions were performed in 7 patients with chronic pancreatitis and external pancreatic fistulas, lithiasis in Wirsung's duct (n = 5) and pancreatic duct strictures (n = 6). A total of 17 procedures were performed, 7 of 8 fistulas were closed. Complications developed in 3 observations, no lethal outcome was registered.Conclusion. Transfistula interventions in pancreatic ducts with combined X-ray guidance, oral and transfistula endoscopy can be used to remove stones, dilate strictures and restore natural passage of pancreatic secretions as an independent treatment or preparation for planned abdominal surgery.

In the period from 2011 till 2012 the Otcreotide-depot was used by the authors in treatment of 34 patients. The patients were divided into two groups: the first group — the prevention of development and the second group — the treatment of external pancreatic fistulas. Ocreotide-depot was applied in 17 patient of the first group: as part of the complex therapy of severe pancreatitis in 4 patients and after pacreaticoduodenectomy in 13 patients. Ocreotide-depot was used in 17 patients of the second group: 7 cases of patients after different types of pancreatic resections and after external drainage of pancreatic cysts in 10 patients. The positive effect of using the drug was obtained in 30 patients (88,25%): the cases of preventive application of drug in 17 patients and during the treatment of external pancreatic fistulas in 13 patients. The preventive and therapeutic usage of Ocreotide-depot facilitated an uncomplicated postoperative period in 13 cases and the healing of the external pancreatic fistulas in terms from 5 till 7 days in 13 patients. The application of Ocreotide-depot could be recommended as a preventive measure against the incompetence of pancreaticojejunoanastomosis after pancreaticoduodenectomy in complex therapy of severe pancreatitis and also in treatment of external pancreatic fistulas after pancreaticoduodenectomy and percutaneous drainage of postnecrotic pseudocysts.