Percutaneous Management of Chronic Pancreatic Duct Strictures and External Fistulas with Long-term Results

Abstract

THE treatment of chronic pancreatitis with severe intermittent abdominal pain or chronic low-output pancreaticocutaneous fistulas remains a major challenge. The 20%–40% of patients who do not respond to intensive medical therapy, including abstinence from alcohol, are traditionally treated by surgical resection or drainage of the diseased pancreas; surgery leads to partial or complete pain relief in 60%– 90% of cases of ductal obstruction, but with a mortality rate of 2%–5% and a serious complication rate of 20%–40% (1–3). Evolving endoscopic pancreatic duct drainage and stent placement procedures (4–7) for treating pancreatic duct (PD) strictures, sealing PD disruptions, and draining PD pseudocysts can offer an alternative to surgery with low major morbidity and mortality. There remains a small group of patients for whom endoscopic and surgical treatment of PD obstruction or fistulas is not possible or advisable; it has been shown in a few case reports that the management of these patients by percutaneous PD drainage with or without stent placement can be effective (8–10). We describe a variety of interventional techniques that we have used to successfully treat five patients with chronic fistula or severe pancreatic pain syndrome, after both surgery and endoscopic catheterization had failed. A follow-up of 5–10 years was possible in most cases.