Pancreatic stent therapy for pancreatic fistulae

Abstract

PANCREATIC STENT THERAPY FOR PANCREATIC FISTULAE DR Lichtenstein A Roston, A Slivka, S Tanner, DC Brooks, PA Banks, DL Carr-Locke. Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Background: Fistulous tracts from the pancreatic duct (PD) may communicate externally with the skin (pancreatico-cutaneousPC)or internally with the peritoneal (pancreatico-peritoneal PP) or pleural (pancreatico-pleural PL) cavities. Traditional approaches to the management of these fistulae have included conservative medical therapy and surgery, although the former fails in up to 50% of cases and the latter is associated with significant morbidity. Patients: In a period of 17 months (May 1993-Sept 1994), we attempted endoscopic insertion of pancreatic stents or drains in seven patients with pancreatic fistulae. There were five males and two females, mean age 53 (range 28-72). The nature of the fistulae were PC in two, PL in two, and PP in three. Five of the patients (2PC, 1PP, and 2PL) had been unsuccessfully treated with octreotide prior to stenting. The etiology of the fistulae included ethanol-induced chronic pancreatitis (2 PL), idiopathic acute pancreatitis (PC), acute panereatitis secondary to pancreas divisum (PP), operative injury during splenectomy (PP) and nephrectomy (PC), and Vou HippeI-Lindau disease (PP) Results: ERP demonstrated the fistulae in all patients. The mean duration between clinical presentation and pancreatic stenting was 3.5 weeks Transpapillary PD stents of 5,7, &l 0 French diameter were inserted in five patients, with the intention of the leak by placing them beyond the site of PD disruption. A short stent was placed in the patient with operative injury to the tail of the pancreas following a splenectomy. There were two endoscopic failures due to an obstructing intraductal PD stone (PP) and a PD stricture (PC), both preventing stent placement and thus necessitating surgical management. All other patients had complete resolution of symptoms as well as fistula closure documented clinically and by ERP at the time of stent removal. The mean duration of stent therapy was 55 weeks. There were no procedure-related complications and none have developed recurrent fistulae. Conclusions: 1) ERCP is a safe and accurate method for demonslrating the site and context of pancreatic fistulae. 2) Endoscopic drainage is an appropriate non-surgical therapy for pancreatic fistulae irrespective ofefiology. 3) Possible mechanisms for fistula closure incIude equilibration of elevated intraductal pressure and/or stent bridging of the disruption acting as a mechanical seal. 4) The stent must cross the site of obstruction in the presence of a coexistent distal pancreatic duct stricture.