Endoscopic Failures Research Articles

Steroid Injection for Benign Refractory Pyloric Stenosis

Purpose: Several studies have demonstrated good rates of success for the relief of symptoms from pyloric stenosis using through-the-scope balloons. Patients who require more than two dilations are at high risk of endoscopic failure and the need for surgical intervention. Here we describe two refractory patients treated endoscopically using steroid ingection and therefore avoiding surgery. Methods: Two patients presented with gastric outlet obstruction secondary to peptic ulcer disease. Both underwent multiple sessions of through the scope balloon dilation (average 4 sessions) with H. Pylori eradication and high dose PPI. Patients symptoms recurred with very short improvement after each dilation. First patient refused surgery, and the other one had severe comorbidities. 80 mg Kenlog ingection was performed (20 mg in every quadrant of the pyloric opening) after performing balloon dilation. Both patients showed significant improvement with no need for further balloon dilation. Average follow up for these two patients was 18 months. Both patients were kept on PPI. Results: Both patients showed significant improvement with no need for further balloon dilation. Average follow up for these two patients was 18 months. Both patients were kept on PPI. Conclusion: Endoscopic balloon dilation has been used to treat patients with gastric outlet obstruction caused by peptic stricture. Surgery is associated with significant morbidity and mortality and should be reserved for endoscopic treatment failures. Benign pyloric stenosis can be readily treated with endoscopic balloon dilation and should be the first-line therapy. Steroid injection should be considered early in the paradigm of treating benign pyloric stenosis especially refractory cases and before consideration for surgery.

Identification of service failures of cylinder valves of ship piston combustion engines

Identification of service failures of cylinder valves of ship piston combustion engines This paper presents selected diagnostic problems of charge exchange system of ship piston combustion engines. Theoretical background of wear process of cylinder valves was highlighted in the aspect of identification and sources of known and identifiable states of unserviceability. The presented results of endoscopic examinations concern failures of cylinder valves of the engines installed on Polish Navy ships.

The Role of Multiple Parallel Stents in the Management of Post-Orthotopic Liver Transplantation (OLT) Biliary Anastomotic Strictures (AS)

Background: Efficacy of multiple parallel biliary stents for post-OLT AS has not been reported. Methods: We conducted a retrospective study of ERCP post-OLT to characterize biliary strictures and outcome of endoscopic therapy. Initial management of strictures was single stent placement. If the stricture persisted at the time of stent removal, parallel stents were placed, generally after balloon dilation. The number of parallel stents was increased every 4-8 weeks until the maximum number felt to be safely accommodated by the duct was reached. Biliary reconstruction (BR) was undertaken for endoscopic failures or progressive liver dysfunction. Results: From 3/01 to 11/06, OLT was performed in 301 patients of whom 75 (25%) underwent 194 ERCPs (mean 2.6 ERCP per patient). Bile duct cannulation at initial ERCP was successful in 72 (96%). There were no cases of post-ERCP pancreatitis or major complications. Biliary strictures were seen in 48 of 72 patients (67%), of which 21 (44%) were early (<90 days) and 27 (55%) were late. 45 patients had AS. Associated findings were intra-hepatic strictures (IHS) in 5, filling defects in 18 and bile leak in 2. 3 had only IHS. 6 AS were diagnosed after an initial normal ERCP with a mean interval from initial to diagnostic ERCP of 581 days. Initial management of AS was single stent in 41 (91%), conservative management in 1 (2%) which resolved, and direct surgery in 3 (7%): 1 re-OLT, 2 BR for high-grade eccentric strictures precluding guide wire passage. Outcome of single stent was resolution in 23 (56%), parallel stenting in 12 (29%) and surgery in 6 (15%, 4 re-OLT, 2 BR for large stones proximal to high-grade strictures). 68% of early strictures resolved with single stent versus 39% of late strictures. Parallel stents were generally 10 Fr and the mean maximum number of stents was 3.25 (range 3-5). Outcome of parallel stents was resolution in 6 (50%), currently ongoing stenting in 3 (25%) and surgery in 3 (25%; 2 re-OLT, 1 BR for persistent AS and IHS). Overall, 12/45 (27%) patients had surgery: 7 (16%) re-OLT and 5 (11%) BR. In no case was failure of multiple parallel stents the indication for surgery. All 8 patients with IHS (5 with and 3 without AS) required re-OLT. Conclusions: 1. ERCP is a safe and effective approach to diagnosis and management of post-OLT biliary AS; 2. An initial normal ERCP does not exclude a subsequent stricture development; 3. Early AS may be primarily related to edema and frequently resolve with single stent; 4. Parallel stent placement is an effective therapeutic option in patients with persistent AS; 5. Patients with IHS likely representing ischemic bile duct injury frequently require re-OLT.

Two-Stage Transperineal Management of Posterior Urethral Strictures or Bladder Neck Contractures Associated with Urinary Incontinence after Prostate Surgery and Endoscopic Treatment Failures

ObjectivesThe treatment of posterior urethral strictures or bladder neck contracture associated with severe urinary incontinence after prostate surgery and failure of endoscopic treatments is controversial. We report our experience with a transperineal approach in two steps: end-to-end urethroplasty/anastomosis and subsequent artificial urinary sphincter implantation. MethodsBetween September 2001 and January 2005, we observed six patients (58–68 yr old), with a combination of severe urinary incontinence and posterior urethral stricture with anastomotic bladder neck contracture after prostate surgery. In all cases, repeated endoscopic treatments of the strictures failed. The patients underwent transperineal end-to-end urethroplasty or anastomosis followed by transperineal artificial urinary sphincter placement after 6 mo. ResultsAfter the first surgical step, all patients were completely incontinent with absence of urethral strictures and complete anastomotic healing in all cases. Therefore, all patients underwent artificial urinary sphincter insertion. After a mean follow-up of 38 mo (range: 18–57 mo), five patients are continent with no postvoid residual urine and a perfectly functioning device. One artificial urinary sphincter was removed due to urethral erosion. ConclusionsIn patients with posterior urethral strictures or bladder neck contractures associated with severe urinary incontinence, an artificial urinary sphincter implantation as a second step allows verification of the outcome of a previous end-to-end urethroplasty or anastomosis and utilizes a dedicated operative field to reduce the risks of prosthesis implants.

Pediatric Endoscopic Dacryocystorhinostomy Failures: Who and Why?

The objectives of this study are to report outcomes of pediatric patients with nasolacrimal duct obstruction (NLDO) who underwent primary endoscopic dacryocystorhinostomy (DCR) and discuss causes of failure. The authors conducted a retrospective case series. Charts of all patients less than 16 years of age who underwent primary endoscopic DCR from 1997 to 2004 were reviewed. Patients were grouped based on the presence or absence of facial anomalies or syndromes and whether the NLDO was congenital or acquired. Success was defined as complete resolution of symptoms, improvement included anatomic patency or partial symptoms, and failure as no improvement or demonstration of patency. Thirty-four patients (43 ducts) aged 11 months to 14 years were identified. There were 17 males and 17 females. Follow up ranged from 2 to 54 months (average, 21 months). Twenty-four patients (29 ducts) had congenital NLDO, seven patients (11 ducts) had congenital syndromes associated with craniofacial abnormalities, and three patients (three ducts) had acquired NLDO. In patients with congenital NLDO without craniofacial abnormalities or syndromes, 22 of 29 eyes (76%) were cured with another three (10%) showing improvement. Only one of 11 (9%) eyes of patients with congenital craniofacial abnormality or syndrome experienced complete resolution and only four of 11 (36%) eyes showed improvement. Of the patients with acquired NLDO, two of three (67%) of the eyes were cured and one (33%) improved. Endoscopic DCR is safe and effective for most children, although patients with craniofacial abnormalities or syndromes are extremely difficult to cure.

Die akute gastrointestinale Blutung aus der Sicht des interventionellen Radiologen – Möglichkeiten und Grenzen

Currently, interventional radiological techniques are an accepted part of the multidisciplinary treatment of the patient with acute massive gastrointestinal hemorrhage. The main limitation to its wider use in arterial hemorrhage is the visualisation of the bleeding lesion by catheter angiography. In arterial gastro-duodenal hemorrhage transcatheter embolisation plays a minor role as compared to endoscopic techniques, but remains an option for endoscopic treatment failures and inoperable patients. Acute transpapillary bleeding are best addressed by radiological means. Microcatheter embolisation of small bowel and colonic bleeding has proven to be safe and efficacious in the emergency setting. The transjugular intrahepatic porto-systemic shunt (TIPS) with or without transvenous variceal embolisation enables the control of almost any acute variceal bleed. The prevention of rebleeding has further improved since the introduction stentgrafts. Its wider use is limited by the TIPS-related encephalopathy.

Treatment of watermelon stomach

Watermelon stomach (WMS), or gastric antral vascular ectasia, is an uncommon but clinically important cause of chronic occult or overt gastrointestinal (GI) blood loss. Patients typically present with symptomatic anemia and hemoccult positive stools. Although the diagnosis is based primarily on the typical endoscopic appearance, the lesion may be overlooked on initial evaluation or interpreted as "gastritis." Gastric biopsy may be helpful in confirming the diagnosis by showing vascular ectasia, typically without inflammation. WMS is idiopathic but is often associated with autoimmune diseases or cirrhosis of the liver. The majority of patients with classic WMS are elderly and female. In contrast, there is no gender predominance with the diffuse pattern associated with cirrhosis. General supportive care includes transfusion of blood products as necessary to control symptomatic anemia and coagulopathy, iron replacement therapy by oral or parenteral routes, identification and treatment of iatrogenic (eg, warfarin) or hereditary (eg, von Willebrand's disease) coagulopathy, and avoidance of substances that might cause gastric mucosal damage and/or bleeding (eg, aspirin, NSAIDs, alcohol). The goals of therapy are to eliminate or decrease the need for blood transfusions, hospitalization, office visits, and endoscopic therapy sessions aimed at cessation of GI blood loss and resolution of symptomatic anemia. Multipolar electrocoagulation is our preferred technique for endoscopic ablation of WMS. A 10-Fr probe (3.2 mm in diameter) is used at a generator setting of 12 to 16 W. Pulse duration can be as short as 1 to 2 seconds if a pinpoint coagulation technique is used, or continuous if a paint-stroke technique is used to coagulate all vascular stripes in the classic WMS pattern or as many small lesions as possible in the diffuse type. Other techniques we currently use are argon plasma coagulation (APC) or heater probe. In the past, lasers (neodymium: yttrium-aluminum-garnet , KTP, or argon) were successfully used for such treatments. An initial treatment interval of 4 to 8 weeks should allow for interim healing of iatrogenic ulcers. Patients are routinely given standard doses of available proton-pump inhibitors (PPIs) to facilitate healing of iatrogenic ulcers and to prevent secondary bleeding. The treatment interval can be gradually lengthened as the long-term goals of obliteration of angiomata and resolution of anemia are reached. Side effects may include iatrogenic ulceration at the site of treatment, bleeding, and transient abdominal pain. Antral scarring (after APC or Nd:YAG laser) and hyperplastic polyps have also been reported after endoscopic treatment of classic WMS. Surgical antrectomy is very effective in the prevention of bleeding but has substantial (5% to 10%) mortality in older patients with comorbidity and is now reserved for endoscopic failures.

Surgical Revision of the Failed Obliterated Frontal Sinus

Surgical revision of failed frontal sinus obliteration, traditionally, has been limited to repeat obliteration. However, endoscopic techniques may be successful in selected cases. We review our experience in surgical revision of failed frontal obliteration and propose a management algorithm. Retrospective chart review was performed over a 5-year period for patients who presented for surgical revision of a previously obliterated frontal sinus. Indications for surgery, radiological findings, and surgical approach were reviewed. Nineteen patients were identified, presenting an average of 9.7 years from the initial obliteration. Eighty-four percent (n = 16) were approached endoscopically and 16% (n = 3) were approached by revision obliteration. The mean follow-up was 25 months. In the endoscopic group, patients had either mucoceles in the inferomedial aspect of the frontal sinus or incomplete obliteration with persistent disease in the pneumatized frontal remnant. Eighty-one percent (13/16) were managed successfully with a single endoscopic procedure. Nineteen percent (3/16) had persistent disease requiring either a subsequent obliteration or Riedel ablation because of infected fat graft or frontal osteomyelitis. All patients who were managed successfully endoscopically remained free of disease with patent frontal sinusotomies throughout the follow-up period. The endoscopic failures required one to two additional external procedures to achieve disease resolution. In the revision obliteration group, all patients had mucoceles in either the lateral or the superior frontal sinus. All three patients had resolution of disease after a single procedure and remained free of disease throughout the follow-up period. Selected patients undergoing revision of frontal obliteration may benefit from endoscopic approaches. If disease is localized in the frontal recess or inferomedial frontal sinus, endoscopic management may be successful in the majority of patients. Superior or lateral frontal disease appears to be best approached externally. Patients undergoing endoscopic salvage should be counseled about the possible need for revision obliteration if disease persists.

Chirurgische Therapie der portalen Hypertension

A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective and durable procedures to control variceal bleeding in patients with low operative risk and good liver function (Child A). In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) or a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergent endoscopic treatment or TIPS insertion fail to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) can be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.

Current state of portosystemic shunt surgery.

A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective, and durable procedures to treat variceal bleeding in patients with low operative risk and good liver function. In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) and a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergency endoscopic treatment or transjugular intrahepatic portosystemic shunt insertion fails to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) should be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.

Medical management in functional endoscopic sinus surgery failures.

Functional endoscopic sinus surgery has a high rate of success, ranging from 75 to 95% improvement in symptoms for patients who have medically refractory chronic rhinosinusitis. However, symptom improvement does not necessarily correlate with disease resolution, and even asymptomatic patients may require long-term medical management and endoscopic surveillance if late recurrence is to be avoided. The 5 to 25% percent of patients who continue to have symptoms create a challenge for the rhinologist. Correct diagnosis is the hallmark of successful treatment of this recidivistic population, carried out through history, nasal endoscopy, and radiologic (computed tomography) studies. Particularly in patients with a primary complaint of headache or facial pain, the initial preoperative diagnosis should also be revisited, particularly before further surgical intervention is considered. Once a proper diagnosis is made, management is multifaceted, including topical and systemic medications, and mechanical improvements in the sinus drainage pathways, either through treatments in the office or revision surgery. Therefore, we strongly recommend that chronic rhinosinusitis be viewed as a medical disease in which surgery plays a therapeutic role. Frequently, persistent inflammation slowly settles down over time with appropriate medical management.

Technical reasons for endoscopic sinus surgery failures

Technical reasons for endoscopic sinus surgery failures

Factors associated with failure of endoscopic injection haemostasis in bleeding peptic ulcers.

The effectiveness of a submucosal injection of adrenaline solution in endoscopic haemostasis is well documented in patients suffering from peptic ulcer bleeding. After treatment, however, a significant number of patients continue to bleed or rebleed, and require emergency surgical intervention. The aim of this study was to define factors associated with the failure of endoscopic injection haemostatic therapy in peptic ulcer bleeding. In the period 1992 to 1998, we prospectively studied all patients suffering from peptic ulcer bleeding and identified endoscopically as being either bleeding actively or carrying a visible vessel. A total of 427 patients (343 men and 84 women; mean age 58.6 +/- 16.6 years) were all subjected to endoscopic injection with adrenaline solution on an emergency basis. Patients who eventually required surgical intervention for permanent haemostasis were considered as endoscopic haemostasis failures, whereas those who did not were considered as endoscopic treatment successes. We evaluated all clinical and endoscopic parameters that might have been related to failure of endoscopic injection therapy. Endoscopic injection haemostasis was successful in 341 patients (79.9%) and a failure in 86 (20.1%) who finally underwent emergency surgical haemostasis. On analysing the examined parameters, failure was significantly related to shock on admission (OR 2.31, 95% CI 1.33, 6.97), spurt bleeding at endoscopy (OR 2.45, 95% CI 1.51, 3.98), posteriorly located duodenal ulcer (OR 2.48, 95% CI 1.37, 7.01) and anastomotic ulcer (OR 3.39, 95% CI 1.37, 7.29). Endoscopic injection haemostasis therapy was less effective in patients with chronic ulcers compared to those who had acute NSAID-related ulcers. A history of peptic ulcer (OR 1.57, 95% CI 1.14, 3.05), previous peptic ulcer bleeding (OR 2.45, 95% CI 1.51, 3.98) or non-use of NSAIDs (OR 2.81, 95% CI 1.33, 4.62) were negative predictors for the outcome of endoscopic haemostasis. With the use of specific clinical and endoscopic characteristics it is possible to define a subgroup of high-risk patients for continued bleeding or rebleeding despite endoscopic injection therapy. These patients may be candidates for intensive monitoring, early surgical intervention or possibly complementary endoscopic haemostatic methods.

Management of acute variceal haemorrhage.

Endoscopic therapy and in particular endoscopic variceal banding ligation, in experienced hands, is the treatment of choice for acute variceal bleeding which remains a major cause of death in patients with cirrhosis and portal hypertension. Pharmacological therapy with Glypressin or somatostatin can be useful to gain time when the endoscopic expertise is not available or to help to obtain a clearer endoscopic view. Transjugular intrahepatic porto-systemic stent shunt is currently used for endoscopic failures, producing similar results with the surgical portacaval shunts. Which one of the two should be preferred, since they both work best in relatively compensated patients, should be a balance between the available surgical and radiological expertise, the urgency of the situation and the expected course of the disease.

Internal stenting in malignant biliary obstruction.

Internal stenting in inoperable malignant biliary obstruction plays an important role in patient management. Surgical bypass may still be undertaken where there is also duodenal obstruction, though the need for gastroenterostomy may be reduced with the increasing use of metallic stents for the relief of malignant gastric outlet obstruction. Stents may be placed endoscopically or percutaneously, though in most centers the endoscopic route is usually tried first, with the percutaneous route being reserved for endoscopic failures. Plastic and self-expanding metallic biliary stents are available, each with its own advantages and disadvantages. In general, longer periods of patency are observed with metallic stents, though they are more expensive. Plastic stents can be changed endoscopically relatively easily when they have blocked, and in practice it is common for plastic stents to be inserted via this route for initial biliary drainage. If there is prolonged survival thereafter, many workers insert a metallic stent in an attempt to reduce the number of interventions required. If the percutaneous route is being employed, the histologic diagnosis has been confirmed, and the malignancy is inoperable, our practice is to use a self-expanding metallic stent, as the delivery system is relatively small and subsequent occlusion less likely.

Management of endoscopic sinus surgery failures

Management of endoscopic sinus surgery failures

Management of unsuspected common bile duct stones found during laparoscopic cholecystectomy by means of transcystic catheter placement and papillary dilation

Background: The optimal treatment strategy for treatment of bile duct stones first diagnosed during laparoscopic cholecystectomy has not been established. We prospectively treated unsuspected bile duct stones by means of intraoperative placement of a transcystic catheter followed by postoperative pharmacologic papillary dilation or endoscopic papillary balloon dilation. Methods: In 17 patients with bile duct stones first found at laparoscopic cholecystectomy, a catheter was introduced via the cystic duct into the bile duct. If postoperative cholangiography via a transcystic catheter showed stones 5 mm or less in diameter, glyceryl trinitrate was infused via the catheter into the bile duct. Patients in whom medical dilation was unsuccessful or who had larger stones underwent endoscopic papillary balloon dilation. Results: Stone diameter measured 3 to 11 mm (mean 6.4 mm). Postoperative cholangiography revealed spontaneous passage in four patients. After pharmacologic papillary dilation, two of five patients with stones 5 mm or less in diameter had stone clearance. The remaining 11 patients underwent successful endoscopic papillary balloon dilation with stone clearance. In two patients, a guidewire introduced via a transcystic catheter through the papilla facilitated selective biliary cannulation. One early minor complication occurred. All patients remained without symptoms for a mean follow-up of 13 months. Conclusion: For unsuspected bile duct stones (usually small ones), this strategy is a simple and effective alternative to laparoscopic bile duct exploration and postoperative sphincterotomy and may minimize early and late complications. Transcystic catheterization ensures access to the bile duct, thereby avoiding endoscopic treatment failures.

Outcome of frontal sinus obliteration.

To evaluate the indications, technique, and results after long-term follow-up of osteoplastic frontal sinusectomy with fat obliteration. A retrospective review of a series of consecutive patients using objective and subjective outcome assessment. A retrospective chart review was conducted of all patients undergoing osteoplastic flap procedure with obliteration between July 1, 1991, and July 1, 1997. Each patient also completed a symptom questionnaire rating the degree of symptoms both before and after surgery using a 10-point scale. The results were tabulated and analyzed for statistical significance. Twenty osteoplastic flap procedures to obliterate the frontal sinus were reviewed. The average patient age was 41 years, with the average duration of follow-up being 40.2 months. No surgical failures were noted; one patient underwent a negative reexploration. One surgical and one medical complication are reported. Statistically significant improvement was noted in overall symptoms, headache, congestion, drainage, and frequency of infections when the preoperative to the postoperative symptom scores were compared (P < .001). Based on these results, the use of the osteoplastic flap in the obliteration of the frontal sinus continues to be an option in the era of endoscopic treatment of frontal sinus disease, particularly in endoscopic failures and chronic frontal sinus pain.

Failures of functional endoscopic sinus surgery and their surgical correction

Endoscopic sinus surgery boasts success rates of 80% to 90%. However, there is a subpopulation of failures who will need to undergo further surgery. The majority of failures can be attributed to anatomic findings that lend themselves to surgical revision with success rates from 69% to 78%. One must, however, be on the lookout for the recalcitrant patient who may have other medical problems complicating his/her sinus disease. Guides to management of the primary functional endoscopic sinus surgery failures are lacking in the literature. These patients must be addressed by isolating the problem area(s) preoperatively with both clinical and radiographic findings. A working knowledge of paranasal sinus surgical anatomy is imperative. Surgical revision can be performed safely after careful preoperative study in a systematic sinus by sinus fashion. Making note of the anatomic landmarks and sinus disease via radiography and examination will prepare the surgeon for the endoscopic diversity and challenge of revision sinus surgery.

Pancreatic stent therapy for pancreatic fistulae

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.