Treatment of Pancreatic Ascites and External Pancreatic Fistulas with a Long-Acting Somatostatin Analogue (Sandostatin)

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.

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.

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.

Endoscopic pancreatic stent insertion for treatment of pseudocyst after distal pancreatectomy

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.

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.

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.

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 fistula due to dehiscence of pancreatico-jejunal anastomosis is still critical complication after pancreatoduodenectomy (PD). This paper describes two cases of intractable external pancreatic fistula following PD that was treated by interventional inner drainage. In case 1. the patient underwent a hepatopancreatoduodenectomy (HPD) for a carcinoma of the gallbladder. Few days after the operation, anastomotic dehiscence became apparent and an external pancreatic fistula was developed. The fistula persisted for about four months after HPD and application of fistulo-jejunostomy was considered. Fistulography was performed and the main pancreatic duct was demonstrated under fluoroscopy. Cannulation into the main pancreatic duct and into the jejunal lumen on the opposite side was accomplished and a stest tube was placed to connect the both channel. The second patient underwent pylorus preserving PD (PpPD) for a carcinoma of the papilla of Vater but it also coursed pancreatico-jejunal anastomotic dehiscence and intractable external pancreatic fistula. The patient was administered a somatostatin analogue. It decreased fistula output but failed to achieve complete closure of the fistula. Cannulation into the pancreatic duct and jejunum was accomplished in the same way and a drainage tube was inserted into the pancreatic duct and placed through the jejunum via percutaneous transhepatic route. In both cases, pancreatic fistula was successfully closed within a day. These interventional endoprostheses are very useful for treatment of inactable 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 Endocrine and Pancreatic Unit at the University of Verona, Italy

Roux-en-Y fistulojejunostomy as a salvage procedure for displaced pancreatic stent in disconnected pancreatic duct syndrome with refractory external pancreatic fistula

Conservative management of pancreatic fistulas resulting from trauma, operation for tumor, or operation for pancreatitis has met with variable success. To assess optimal management strategies and outcome, we reviewed the records of 35 patients with external pancreatic fistulas (26 patients), pancreatic ascites (6 patients), or pancreatic pleural effusion (3 patients). Treatment included no operation in 5 patients, oversewing of the fistula in 7 patients, internal drainage in 11 patients, and resection in 12 patients. One (3%) postoperative death occurred. The overall rate of operative success was 83% (25 patients). The incidence of recurrent fistulas was about the same regardless of the procedure. Patients treated successfully without operation did not have pancreatitis as an underlying disease. Patient selection is of great importance in the decision to resect or to drain and is based in part on imaging the pancreatic duct and fistula.

Preoperative endoscopic transpapillary stenting: A solution to preventing and/or treating postsurgical external pancreatic fistula and infection in patients with infected necrotizing pancreatitis