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

Abstract

Introduction: External Pancreatic Fistulas (EPF) may complicate pancreatic surgery. Management of EPF is difficult and represents a real challenge for endoscopists. Aims and Methods: The aim was to report outcomes of a consecutive series of patients who underwent ERCP for management of EPF, in a single endoscopy center. EPF were classified in 3 main types, according to leak source: type1-side-brach ducts and no main pancreatic duct (MPD) disruption; type2-MPD disruption; type 3-MPD stump after pancreatic resection. Bypass of the leak with stents (PS) or naso-pancreatic drains (NPD) was attempted whenever possible. Peri-pancreatic fluid collections (PFC) were preferably drained trans-papillary into the duodenum. A different treatment was planned according to the fistula type. Bypass of the leak with PS or NPS was usually performed in Type 1. NPD or PS were placed into the MPD disruption in order to hijack pancreatic juice and PFC into the bowel in Type 2. In case of EPF from pancreatic stump after distal pancreatectomy (Type 3a), NPD or PS were placed into the PFC until fistula healing. Pancreatic sphincterotomy (ES) and short PS placement was the preferred treatment in the absence of PFC. In case of EPF from anastomotic dehiscence after Whipple resection (Type 3b), transnasal drainages were placed into the peri-anastomotic PFC for 7-14 days. Results. Between 1991 and October 2007, 53 patients (33 males, mean age 49 years [15-80]) with EPF underwent ERCP with a therapeutic aim. Median time interval between EPF onset and ERCP was 58 days (12-447). Mean fistula output was 159 ml/day (10-800). A type 1 EPF was present in 14 patients; 29 had a type 2; 10 patients a type 3 (type 3a N=6; type3b N=4). Endotherapy was technically unsuccessful in 9 cases (Type1 n=2; Type2 n=5; Type 3a n=2). EPF was cured in 43/44 patients (98%) who had completed endotherapy (mean 5.6 days and 2.6 ERCP per-patient). Successful EPF healing was possible with cyanoacrylate injection into the fistulous tract in 5 patients and transgastric drainage of fluid collections in 2. EPF recurred in 4 patients after a median of 30 days, and re-treated successfully. Early complications (N=6) occurred in 5 patients and one required surgery. A patient died after 24 hours of unrelated causes. Late complications occurred in 6 patients, including a symptomatic MPD stricture and 5 pseudocysts that were managed by endoscopy. No endoscopic-related mortality was recorded. Conclusions: ERCP is effective for therapy of EPF. Treatment should be planned according to EPF location and characteristics. Endoscopic management of EPF should be performed in high volume pancreatic endoscopy centers.