External pancreatic fistula treated by endoscopic ultrasound-guided drainage with a novel lumen-apposing metal stent mounted on a cautery-tipped delivery system

Background and Aims External pancreatic fistula occurring in the setting of disconnected pancreatic duct syndrome leads to significant morbidity, often requiring surgery. The aim of this study is to report a new technique of endoscopic ultrasound (EUS)-guided rendezvous and tractogastrostomy in patients with disconnected pancreatic duct syndrome and external pancreatic fistula. Methods This study is retrospective analysis of the data of the patients with external pancreatic fistula who had undergone EUS-guided rendezvous and tractogastrostomy. Internalization of pancreatic secretions was performed by placing a stent between tract and the stomach. Technical success was defined as placement of stent between the tract and the stomach. Clinical success was defined as removal of external catheter and absence of peripancreatic fluid collection, ascites or external fistula at 3 months after the tractogastrostomy. Results Four patients, all male, with median age of 33.5 years (range: 29–45), underwent EUS-guided tractogastrostomy. Technical and clinical success was 100%, without any procedure related complication. External catheter could be removed in all the patients. During the median follow-up of 10.5 months (range: 8–12), two patients had stent migration and peripancreatic fluid collection, which were managed by EUS-guided internal drainage. Conclusions EUS-guided rendezvous and tractogastrostomy are a safe and effective technique for the treatment of external pancreatic fistula.

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

Вступ. Хронічний панкреатит (ХП) зумовлює виникнення різних ускладнень: функціональних розладів, прогресування недостатності екзо– та ендокринної функції підшлункової залози (ПЗ), формування панкреатичних нориць (ПН), цукрового діабету. Як правило, захворювання виявляють у пацієнтів молодого віку (у середньому 20 – 50 років), що суттєво впливає на соціально–економічний стан у суспільстві.
 Мета дослідження. Покращити результати лікування пацієнтів за ускладненого перебігу ХП, у яких сформувались внутрішні та зовнішні ПН, шляхом індивідуального підходу до діагностики та хірургічної корекції.
 Матеріали і методи. Оперовані 148 пацієнтів з приводу ускладнених форм ХП.
 У 31 (21%) пацієнта виявлені зовнішні та внутрішні ПН. Причиною утворення ПН у 10 (32%) хворих був гострий панкреатит, панкреонекроз, у 20 (64,5%) – ХП, в 1 – травма. У 9 (43%) пацієнтів, яких раніше оперували з приводу гострого панкреатиту, загострення ХП, панкреонекрозу, сформувалася зовнішня ПН, у 5 (55,5%) з них – стійка часткова, у 4 (44,4%) – повна зовнішня ПН внаслідок деструкції протоки ПЗ, дебіт соку понад 400 мл на добу.
 Результати та обговорення. Оперативні втручання виконані у 9 (43%) пацієнтів з приводу ПН.
 Несвоєчасне хірургічне лікування ускладнених форм ХП зумовлює формування внутрішніх та зовнішніх ПН. Для доопераційної верифікації зовнішніх ПН слід проводити ендоскопічну ретроградну холангіопанкреатографію (ЕРХПГ) та фістулографію, для інтраопераційної діагностики та верифікації норицевого ходу – інтраопераційну панкреатовірсунгографію. Основним оперативним втручанням з приводу будь–яких нориць є дренування протоки ПЗ, у деяких ситуаціях – у поєднанні з резекційними методами.
 Висновок. Проблема хірургічного лікування внутрішніх та зовнішніх ПН є актуальною, потребує індивідуального підходу до діагностики, обгрунтування показань до виконання операцій, інколи – етапних оперативних втручань.

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.

Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video)

Endoscopic ultrasonography

Screening for Early Pancreatic Neoplasia in High-Risk Individuals: A Prospective Controlled Study

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.

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

Aim . To analyze the outcomes of pancreatic necrosis depending on the depth and localization of damage to the pancreatic tissue, to determine the main risk factors for the development of external and internal pancreatic fistulas. Materials and methods. The analysis of long-term results of treatment of pancreatic necrosis in 81 patients was carried out: 53 patients were treated at the stage of acute pancreatitis in our clinic, 28 – in other medical institutions. The algorithm of the survey included a CT scan with contrast enhancement, fistulography, MRI-pancreatocholangiography and/or endoscopic retrograde cholangiopancreatography. The influence of various factors on the development of pseudocysts and pancreatic fistulas was estimated using the Spearman correlation coefficient. Results. Signs of damage to the pancreatic duct were detected in 19 (36%) of 53 patients: 9 were diagnosed with pseudocysts, 10 had external pancreatic fistulas. The daily flow rate of pancreatic juice ( α -amylase activity >20950 u/l) was 300–350 ml. Interventions (minimally invasive, open surgery) required 10 patients (52.6%). The correlation coefficient of external pancreatic fistulas with the depth of pancreatic necrosis was 0.46 ( р = 0.00005), the CT severity index according to Balthazar – 0.05 ( р = 0.63), the localization of necrosis in the neck – 0.31 ( р = 0.006), the amount of drainage discharge – 0.55 ( р = 0.000001), the activity of α -amylase fluid – 0.53 ( р = 0.000002). There was a significant positive correlation of mediastinal pancreatogenic cysts with pseudocysts located on the posterior surface of the pancreas ( r = 0.7; p = 0.003), pleural effusion with high activity of α -amylase ( r = 0.87, р = 0.0005) and alcoholic etiology of acute pancreatitis ( r = 0.75, р = 0.002). Conclusion. Predictors of resistant to conservative treatment external pancreatic fistulas are deep necrosis, especially in the area of the neck of the pancreas, the discharge flow rate through the drainage is more than 150 ml with an α -amylase activity of more than 1000 u/l. A risk factor for the development of internal pancreatic fistulas with penetration into the mediastinum is the localization of pseudocysts on the posterior surface of the pancreas in the body and tail area.

External pancreatic fistulas (EPFs) are managed primarily by conservative treatment with a success rate of 40-90%. Failures of conservative therapy have traditionally been dealt with using surgery; however, major morbidity and mortality are associated with operative treatment. The aim of this study was to evaluate the feasibility and effectiveness of endoscopic treatment in the closure of EPF. A total of 16 consecutive patients with EPF (12 men, four women; median age 50, range 21-66) underwent an attempt at endoscopic management after failure of conservative therapy. Four patients had chronic pancreatitis. All patients had EPFs occurring after open abdominal surgery. The mean interval between the onset of the fistula and our intervention was 108 days (range 27-365 days). The mean output volume of the fistula was 205 ml/d (range 50-600 ml/ d). The aim of treatment was to lower the pancreatic duct pressure and to bypass the ductal disruption by placement of drains and/or stents to induce fistula healing. In all, 13 biliary and nine pancreatic sphincterotomies were performed in order to gain access to the pancreatic duct. Access through the minor papilla was required in one patient. Complete visualization of the main pancreatic duct as well as of the fistulous tract was obtained in 12 patients (75%). Treatment consisted of placement of a nasal pancreatic drain (NPD) across the pancreaticojejunal anastomosis in one patient after duodenopancreatectomy. In 11 of the remaining 15 patients (73%) a NPD could be placed in the pancreatic duct across the ductal leakage (n = 9) or nearby (n = 2). One patient died 24 hours after endoscopic treatment from severe sepsis and massive pulmonary embolism. Endoscopic drainage was effective in healing the EPF in all patients in whom NPDs had been successfully placed, except one. The fistula in this patient healed completely after insertion of an 8.5-Fr pancreatic stent. The mean interval between endoscopic treatment and fistula closure was 8.8 days (range 2-33 days). No complications related to the endoscopic treatment were recorded in this series. In the 12 successfully treated patients, fistulas did not recur in any of the 11 surviving patients after a mean follow-up of 24.7 months (range 3-63 months). Endoscopic pancreatic drainage, when feasible, is safe and effective for EPF and should be considered as a first-line therapy when EPFs do not respond to conservative therapy.

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.

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.

Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice in establishing the nature and the site of common bile and pancreatic duct disease and related complications. It was used in 668 Jordanian patients who presented with biliary or pancreatic disease and unexplained upper abdominal pain. Common bile duct (CBD) stones, postsurgical traumatic CBD strictures, papillary stenosis and malignant strictures were the most common findings in this study. The incidence of malignant strictures was less and the postsurgical CBD injuries, mainly CBD complete ligation, were more than what was reported by others. This procedure was also valuable in the investigation of unexplained upper abdominal pain and pancreatic disease.

Tu1395 LONG TERM FOLLOW-UP OF PATIENTS WITH A DISCONNECTED PANCREATIC DUCT FOLLOWING TREATMENT OF WALLED-OFF NECROSIS