Pancreatic Duct Leak Research Articles

Pancreatico-peritoneal Fistula: A Rare Cause of Recurrent Ascites and a Novel Treatment

Introduction: Pancreatico-peritoneal fistula is a rare and clinically challenging cause of recurrent ascites. We report a patient with recurrent ascites secondary to a pancreatic duct leak, and its successful treatment using Coseal® surgical sealant delivered endoscopically. Case Report: A 42-year-old male with a history of alcoholism and presumed alcoholic cirrhosis, presented with worsening ascites, abdominal pain, weight loss, and anorexia. One month prior, the patient underwent outpatient paracentesis, and was started on a diuretic regimen of spironolactone 100 mg and furosemide 40 mg daily. On physical exam, he was febrile and cachectic, with abdominal protuberance and tenderness. Laboratory tests revealed WBC 17.8 K/uL, albumin 2.8 g/dL, total bilirubin 0.9 mg/dL, direct bilirubin 0.4 mg/dL, alkaline phosphatase 161 U/L, AST 75 U/L, and ALT 40 U/L. Paracentesis indicated bacterial peritonitis (5,167 WBC/uL, 99% PMNs), and intravenous cefotaxime was initiated. Despite antibiotics, the leukocytosis and symptoms persisted. CT scan revealed three pancreatic pseudocysts, scattered pancreatic calcifications, and a 5-mm pancreatic duct in the tail, along with large ascites but no evidence of cirrhosis. Subsequent large volume paracentesis revealed elevated ascitic fluid amylase (43,869 U/L), and cultures isolated Pseudomonas aeruginosa. Given the CT findings and the high ascitic fluid amylase, the diagnosis of a pancreatico-peritoneal fistula was suspected. ERCP revealed a moderate pancreatic duct stenosis in the body with a small stone proximal to the stricture, as well as a pancreatic duct leak originating from the tail. A 7 Fr x 11 cm straight pancreatic stent was successfully placed and antibiotic coverage with imipenem was maintained, yet the patient's symptoms and ascites with high amylase content persisted. Repeat ERCP re-demonstrated extravasation of contrast from the pancreatic tail. Coseal® surgical sealant was then injected through a catheter into the tail of the pancreatic duct for closure, and an 8.5 Fr x 14-cm pancreatic stent was placed. Within days, the patient's symptoms improved, and he remains stable at 3 months after fistula closure. Conclusion: Ascites from a pancreatic-peritoneal fistula is rare, and it poses a significant diagnostic and therapeutic challenge. Given the patient's alcohol history, the true etiology of his ascites and peritonitis was initially misdiagnosed. Once properly recognized, the pancreatico-peritoneal fistula was successfully closed by applying a surgical sealant delivered endoscopically.

ERCP in the management of pancreatic diseases in children

ERCP experience in pancreatic disorders in children is limited. This study evaluated the utility and efficacy of ERCP in children with pancreatic diseases at a tertiary care referral center. Consecutive patients 18 years of age and younger who underwent ERCP for pancreatic diseases from January 2010 to June 2011 were identified. Indications, findings, interventions, adverse events, and outcomes were recorded. A total of 221 ERCPs were performed in 172 children (102 boys, mean ± standard deviation age 13.8 ± 3.2 years, 157 therapeutic). A total of 143 children (83.1%) had chronic pancreatitis (CP), 19 (11%) had recurrent acute pancreatitis (RAP), and 10 (5.8%) had acute pancreatitis (AP). Indications included pain (153, 89.4%), pancreatic fistula (11, 6.3%), symptomatic pseudocyst (4, 2.3%), and jaundice (3, 1.7%). In chronic pancreatitis patients, findings included a dilated and irregular main pancreatic duct (92, 64.3%), pancreatic duct (PD) calculi (76, 53%), dominant PD stricture (23, 16%), PD leak (7, 4.9%), pancreas divisum (35, 24.5%), and common bile duct (CBD) stricture (3, 2%). Therapeutic procedures included major papilla sphincterotomy (93, 65%), minor papilla sphincterotomy (32, 22.3%), PD stenting (77, 53.8%), and CBD stenting (3, 2.2%). PD stones larger than 5 mm were retrieved endoscopically after 57 extracorporeal shock wave lithotripsy sessions in 50 patients (34.9%). In patients with RAP, 6 (31.5%) had complete and 1 partial pancreas divisum. All underwent minor papillotomy. In patients with AP, 4 (40%) had stenting for PD leak, 2 (20%) underwent CBD clearance for biliary pancreatitis, and 4 (40%) had transpapillary pseudocyst drainage. During 13 ± 4.7 months (range 6-22 months) of follow-up, improvement of symptoms was seen in 143 of 172 (83%) patients. Procedure-related adverse events were seen in 8 (4.7%) patients. Retrospective study. ERCP is a safe therapeutic option for pancreatic disorders in children.

Multimodality endoscopic treatment of pancreatic duct disruption with stenting and pseudocyst drainage: How efficacious is it?

BackgroundFew studies have described the role of multimodality therapy and the complexity of endoscopic management of pancreatic duct disruption. Our study aim was to analyse and confirm factors associated with the resolution of pancreatic duct disruption. MethodsOver 6 years, retrospective data on patients with pancreatic duct disruption managed endoscopically were retrieved. Success was defined as resolution of the pancreatic duct disruption at 12 months. Logistic regression analysis was performed to determine factors associated with resolution. Results113 patients (78 male) with a mean age 51.3 year were included. Resolution of the pancreatic duct leak occurred in 80 cases (70.2%). 72 cases received transpapillary pancreatic duct stents, with 51 demonstrating resolution of pancreatic duct leak (71%) cystenterostomy was performed in 68 patients with 51 resolved (75%). In partial duct disruptions, pancreatic duct stenting combined with endoscopic drainage of fluid collections resulted in an increased rate of resolution (80%) compared to complete disruptions treated in a similar manner (57%). In complete pancreatic ductal disruptions, transpapillary pancreatic duct stenting had no additional benefit (9/17, 52.9%) compared to cystenterostomy or percutaneous drainage alone (24/34, 70.6%; P=0.61). ConclusionPancreatic duct disruptions require multimodality treatment, addressing not only the integrity of the pancreatic duct but also any fluid collections associated. Partial ductal disruption should be managed by a bridging stent.

MEN I Associated Insulinoma and Zollinger Ellison Syndrome Presenting with Syncope

Purpose: A 24-year-old woman with a history of prolactinoma, neurofibromas and parathyroid hyperplasia reported a 3-month history of fainting episodes. She was found to have a FS glucose <30, an elevated serum insulin of 130 mU/ml, a normal C-peptide and CT scan revealed an enhancing 3.4-cm pancreatic body lesion. An insulinoma was suspected and the patient had a subtotal pancreactectomy with pathology identifying a 3.5-cm well-differentiated neuroendocrine tumor and two smaller 1.5- and 0.5-cm nodules in the pancreatic tail all with immunostaining positive for insulin and negative for PTH and gastrin, consistent with Beta cell tumor. The patient had persistent JP drain output concerning for a pancreatic duct leak. ERCP was performed which was notable for LA class C distal esophagitis, clean based fundic ulcer and multiple clean based duodenal ulcers including a large 2-cm ulcer adjacent to the ampulla. Serum gastrin level was elevated at 3,324 pg/ml, consistent with Zollinger-Ellison Syndrome with a constellation of findings suggestive of multiple neuroendocrine neoplasm I (MEN I). The diagnosis of insulinoma is often delayed due to the non-specific symptoms. Nearly 90% of insulinomas are solitary, benign and less than 1.5 cm in diameter. However, those associated with MEN I are usually multiple. Reports indicate CT imaging can identify tumors less than 1 cm with a sensitivity of 40-73% and MRI increases that number to 85-95%. EUS can identify lesions as small as 5 mm with sensitivity approaching 95%. This patient's presentation and history suggested MEN I in which efforts to identify the more aggressive, multiple lesions could be made utilizing EUS. We recommend further studies evaluating the role of pre-operative EUS tumor localization in suspected MEN I associated neuroendocrine tumors.Figure: Enhancing mid pancreatic lesion.Figure: [776] Pathology specimen demonstrates pale 3.5 cm mass in the pancreatic body.

Covered self-expanding metal stent use in the pancreatic duct: a case series

Plastic stents have been used in the pancreatic duct for a variety of indications. However, unlike in the bile duct, the use of covered self-expanding metal stents (CSEMSs) has been discouraged because multiple side branches drain into main pancreatic duct (MPD) and the ductal diameter is relatively small. This report aims to describe our experience using CSEMSs in the pancreatic duct in a series of nine patients, with special focus on adverse events. Indications were strictures (n = 5), intraductal mucinous neoplasm (IMPN; n = 1), pancreatic duct leak (n = 1), disconnected duct syndrome (n = 1), and severe acute pancreatitis/necrosis with disrupted duct (n = 1). Eight patients had symptomatic improvement, or radiological resolution of or improvement in their strictures, leaks, perforation, and necrosis. Two of these have indwelling CSEMSs for ongoing treatment. One patient (disconnected duct syndrome) was considered a treatment failure as the stent migrated and the patient underwent distal pancreatectomy for refractory pain. Two patients underwent pancreaticoduodenectomy for their malignancies after their CSEMSs had been in place for 43 and 49 days, respectively. Importantly no patients, including those with indwelling CSEMSs, developed stent-related acute pancreatitis with a median follow-up of 4 months. One patient developed post-procedure pain requiring hospitalization for 1 day. Median stent duration was 77 days. These observations suggest there is a potential role for the use of CSEMSs in the MPD in selected patients with pancreatic pathology.

Not Your Typical Case Of Ascites: Pancreatic Ascites In A Patient With Cirrhosis And Pancreatic Duct Leak

Case A 55-year-old male with a history of hepatic cirrhosis secondary to Hepatitis C and alcohol abuse presented to an outside hospital with progressive abdominal pain and distension. The patient initially complained of “punching” right upper quadrant and epigastric abdominal pain that was 10/10 in intensity and non-radiating. Although the pain had started one to two days prior to presentation, the patient had been experiencing several weeks of increasing abdominal distension. He reported drinking eight 40oz beers daily for over 40 years, and he felt that the abdominal pain improved slightly with cessation of alcohol use. The patient complained of nausea and non-bloody, non-bilious vomiting, progressive dyspnea on exertion, and worsening lower extremity edema. He denied fevers or chills.

Roles of Endoscopic Intervention for Chronic Pancreatitis

Chronic pancreatitis is a debilitating disease with complications such as pancreatic duct stricture, duct stones, duct leak or fistulae, pseudocyst contributing to significant morbidity and mortality. Endoscopic intervention in patients with chronic pancreatitis compared to surgery has been known relatively safe and effective. Although there are several limitations, endoscopic intervention plays a specific role in carefully selected patients as primary interventional therapy when medical treatment was failed or patients are not suitable for surgery. In this review, we address the role of endoscopic intervention for chronic pancreatitis.

Endoscopic Transmural Drainage of Peripancreatic Fluid Collections: Outcomes and Predictors of Treatment Success in 211 Consecutive Patients

ObjectivesEndoscopy is a minimally invasive technique for the drainage of peripancreatic fluid collections. This study evaluated the clinical outcomes and predictors of treatment success in consecutive patients undergoing endoscopic transmural drainage of peripancreatic fluid collections. MethodsThis is a retrospective study of patients who underwent endoscopic drainage of peripancreatic fluid collections over 7 years. Prior to drainage, an ERCP was attempted for stent placement in all patients with a pancreatic duct leak. Drainages were performed using conventional endoscopy or endoscopic ultrasound. Transmural stents and/or drainage catheters were deployed and endoscopic necrosectomy was undertaken when required. Data on clinical outcomes and complications were collected prospectively. ResultsA total of 211 patients underwent drainage of peripancreatic fluid collections that was classified as pseudocyst in 45%, abscess in 28%, and necrosis in 27%. Mean diameter of the fluid collection was 100.6 mm, and 34.5% of patients had pancreatic duct stent placement. Median duration of follow-up was 356 days. Treatment success was 85.3% and was higher for pseudocyst and abscess compared to necrosis (93.5% vs. 63.2%, p < 0.0001). Complications were encountered in 17 patients (8.5%) and was higher for drainage of necrosis than pseudocyst or abscess (15.8% vs. 5.2%, p = 0.02). Treatment success was more likely for patients with pseudocyst or abscess than necrosis (adjusted OR = 7.6, 95% CI [2.9, 20.1], p < 0.0001) when adjusted for serum albumin and white cell count, type of endoscopic modality or accessory used, pancreatic duct stenting, luminal compression, size and location of fluid collection. ConclusionsEndoscopic therapy is a highly effective technique for the management of patients with non-necrotic peripancreatic fluid collections.

Endoscopic Therapy in Chronic Pancreatitis

Chronic pancreatitis (CP) is a debilitating disease that can result in chronic abdominal pain, malnutrition, and other related complications. The main aims of treatment are to control symptoms, prevent disease progression, and correct any complications. A multidisciplinary approach involving medical, endoscopic, and surgical therapy is important. Endoscopic therapy plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in patients who are not suitable for surgery. Endoscopic therapy is also used as a bridge to surgery or as a means to assess the potential response to pancreatic surgery. This review addresses the role of endoscopic therapy in relief of obstruction of the pancreatic duct (PD) and bile du ct, closure of PD leaks, and drainage of pseudocysts in CP. The role of endoscopic ultrasound-guided celiac plexus block for pain in chronic pancreatitis is also discussed.

What is the role of endotherapy in chronic pancreatitis?

Chronic pancreatitis (CP) can have debilitating clinical course due to chronic abdominal pain, malnutrition and related complications. Medical, endoscopic and surgical treatment of CP should aim at control of symptoms, prevention of progression of the disease and correction of complications. Endoscopic management plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in high-risk surgical candidates. Endotherapy for CP is utilized also as a bridge to surgery or to assess potential response to pancreatic surgery. In this review we address the role of endotherapy for the relief of obstruction of the pancreatic duct (PD) and bile duct, closure of PD leaks and drainage of pseudocysts in the setting of CP. In addition, endotherapy for relief of pancreatic pain by endoscopic ultrasound-guided celiac plexus block for CP is discussed.

Are Large Side Holes Associated with Reduced Rates of Pancreatic Stent Occlusion? Results of a Prospective, Multi-centered Study

Purpose: Pancreatic stents are frequently clogged at the time of removal. There is limited data regarding the factors associated with stent occlusion. Methods: Consecutive patients at 4 academic medical centers undergoing removal of a previously placed pancreatic stent were prospectively enrolled. Following removal, stent occlusion was immediately assessed by complete lack of water flow from the duodenal end and side holes of the stent. Survival analysis was performed using a Kaplan-Meier and Cox Regression model. Results: Total of 68 patients were enrolled between August 2007 and July 2008. Indications for stent placement included chronic pancreatitis (CP) (n=23), pancreatic duct (PD) leak (n=7), prevention of post-ERCP pancreatitis (n=28), pseudocyst drainage (n=l), pancreas divisum (n=8), and PD stricture without CP (n=1). Standard Geenen® pancreatic stents were placed in 77.9% patients. The majority of stents (61.8%) were completely occluded at the time of removal. Median time to stent occlusion was 35 days (95% CI=30-40d). The characteristics of the stents are listed in Table 1. Stent type, diameter, length, number of small side holes, and indication for placement were not predictive of subsequent stent occlusion (Table 2). However, stents with at least 4 large, flange-associated side holes were 54% less likely to be clogged upon removal (HR=0.46, p=0.029).Table 1: Results of univariate analysis: hazard ratios (HR) for all stent-related variables and indication for placementTable 2: Stent characteristics in 68 patientsConclusion: Pancreatic stents are mostly occluded as early as 1 month after insertion. Larger side holes may prevent stents within the pancreas from becoming clogged.

Surgical Gastrostomy for Pancreatobiliary and Duodenal Access Following Roux en Y Gastric Bypass

BackgroundPancreatobiliary access following Roux-en-Y gastric bypass (RYGBP) is challenging. We reviewed 32 cases of surgical gastrostomy for complex transgastric upper gastrointestinal endoscopy. MethodsRetrospective review of prospectively collected database of patients with history of RYGBP that had surgical gastrostomy for pancreatobiliary and duodenal access at a single institution from 2004–2008. Indication for procedure, surgical findings, successful cannulation, and complications are reported. ResultsThirty patients (25 female), with age ranging from 27 to 72, underwent 32 procedures. The indications to access the gastric remnant were sphincter of Oddi dysfunction (13), pancreatitis (six), common bile duct stone/obstruction (five), cholangitis (three), pancreatic mass evaluation (two), gastrointestinal bleed (two), and cystic duct leak after cholecystectomy (one). Mean operative time was 200 min (98–338) and estimated blood loss (mean) 85 cc (10–500). Laparoscopic gastrostomy was attempted in 28 cases with one conversion to open (3.6%). Four planned open procedures were also performed. All 30 patients underwent successful endoscopy and 28 had an endoscopic retrograde cholangiopancreatography, all with successful cannulation of the pancreatobiliary tree (100%). ConclusionsSurgical gastrostomy is an effective means to gain access to the upper GI tract and pancreatobiliary tree following RYGBP. This technique should be considered when traditional endoscopic approaches are impossible.

Multimodality Endoscopic Treatment of Pancreatic Duct Disruption with Stenting and Transenteric Pseudocyst Drainage: How Efficacious Is It?

Background: Endoscopic management of pancreatic duct disruption is well described in the literature but no prospective study has captured the multimodality aspect and complexity of its management. Our aim is to analyze our experience and identify factors associated with the resolution of pancreatic duct disruption. Methods: Between January 2002 and July 2008, all patients who underwent endoscopic treatment of their pancreatic duct disruption were followed prospectively until complete resolution (n=114 cases involving 113 patients). All patients underwent pancreatic sphincterotomy. In 72 cases a pancreatic duct stent was placed, of which 47 stents crossed the disruption. Success was defined as resolution of the leak at 12 months confirmed by ERCP, MRCP or CT post stent removal. Logistic regression analysis was performed on the following variables with regard to their ability to predict complete resolution: age, gender, etiology, chronicity, pancreatic stenting, endoscopic pseudocyst drainage, percutaneous drainage, type of disruption (partial vs. complete), location of disruption (pancreatic body vs. other), and enteral feeding. Results: 113 patients (78 male), mean age 51.25 years (range 11-86 years) were included. 114 total cases were evaluated. 108 cases presented with pancreatic fluid collection, 3 with pancreatic ascites and 4 with fistula. Resolution occurred in 80 cases (70.2%) at 12 months; while 20 cases (17.5%) did not resolve. 9 cases (7.9%) were lost to follow-up within 12 months of presentation and 5 (4.4%) mortalities occurred unrelated to the procedures. 72 cases (63.2%) underwent pancreatic duct stenting of which 51 resolved (71%). 68 (59.6%) cases required cystenterostomy, of which 51 resolved (75%), and 5 cases (4.4%) required percutaneous drainage. Enteral feeding was employed in 81 cases (71.7%). Logistic regression analysis failed to identify any factor predictive of resolution. In partial duct disruptions, pancreatic duct stenting with endoscopic drainage of fluid collections resulted in an increased rate of resolution at 12 months (76.6%). In cases of complete pancreatic duct leak, the use of pancreatic duct stenting with endoscopic drainage of fluid collections had no additional benefit (14/25, 56%) compared to cystenterostomy alone (24/38, 63.1%) (P value= 0.61). Conclusions: Stenting of pancreatic duct disruptions should only be performed in cases of partial disruption. Complete ductal disruption appears better managed with transenteric drainage of the associated fluid collection. Future randomized control trials are needed for validating these results.

Pancreaticoduodenectomy: frequency and outcome of post-operative imaging-guided percutaneous drainage

To study the frequency and outcomes of percutaneous imaging-guided drainage following pancreaticoduodenectomy and to assess if fluid collection location correlates with pancreatic duct leak. IRB approval was obtained. Three hundred and seventy-three subjects (age 21-84 years) who underwent pancreaticoduodenectomy were included in this retrospective study. Eighty-three of these subjects underwent post-operative imaging-guided drainage (CT 77; US 6). Medical and imaging records were reviewed. Procedural details including collection location, size, catheter size, drain duration, fluid type, fluid chemistry, and fluid culture were recorded. Collection location was correlated with fluid amylase. The frequency of imaging-guided percutaneous drainage following Whipple was 22.2%. The immediate technical and overall success rates for fluid collection drainage were 97.6% and 79.6%, respectively. Rate of complication was 4.8% (4/83). 74.7% (62/83) of fluid collections were proven abscesses, and 61.4% (51/83) were complicated by pancreatic fistula. Collections near the pancreatic resection site were more likely to have elevated fluid amylase. Approximately one-fifth of subjects requires percutaneous drainage following pancreaticoduodenectomy. Percutaneous imaging-guided drainage is an effective means of managing post-pancreaticoduodenectomy fluid collections. Collections near the pancreas resection site often have a pancreatic duct leak.

Distal Pancreatectomy is Not Associated with Increased Perioperative Morbidity when Performed as Part of a Multivisceral Resection

PurposeTo evaluate the indications for and the outcomes from distal pancreatectomy. MethodsRetrospective chart review of 171 patients who underwent distal pancreatectomy at Brigham and Women’s Hospital between January 1996 and August 2005. ResultsNearly one-third of distal pancreatectomies were performed as part of an en bloc resection for a contiguous or metastatic tumor. Fifty-six percent of the patients underwent a standard distal pancreatectomy +/− splenectomy (group 1), whereas 44% of distal pancreatic resections included additional organs or contiguous intraperitoneal or retroperitoneal tumor (group 2). The overall post-operative complication rate was 37%; the most common complication was pancreatic duct leak (23%). When compared to patients undergoing standard distal pancreatectomy, those with a more extensive resection including multiple viscera and/or metastatic or contiguous tumor resection had no significant difference in overall complication rate (35% v. 39%, p = 0.75), leak rate (25% v. 20%, p = 0.47), new-onset insulin-dependent diabetes mellitus (3% v. 4%, p = 1.0), and mortality (2% v. 4%, p = 0.656). ConclusionThis series includes a large number of patients in whom distal pancreatectomy was performed as part of a multivisceral resection or with en bloc resection of contiguous tumor. Complications were no different in these patients when compared to patients undergoing straightforward distal pancreatectomy.

RETRACTED: The Role of Pancreatic Leakage on Rising of Postoperative Complications Following Pancreatic Surgery

The variations in methods of pancreatic stump management and the volume of literature available on both main pancreatic duct and pancreaticoenetric anastomosis leak indicates the concern associated with the leak and the continuing efforts to prevent it. Herein we analyzed the role of pancreatic leakage followed by pancreatic surgery on the incidence of postoperative morbidity. From 1989 to 2005, we performed 76 pancreaticoduodenectomy (PD) and 26 distal pancreatectomy (DP), assumed as control case). During DP the parenchymal transection was performed with a linear stapler. The surgical reconstruction after PD was as follows: 11 manual nonabsorbable stitch closure of the main duct, 24 closure of the main duct with linear stapler, 17 temporary occlusion of the main duct with neoprene glue, and 24 duct-to-mucosa anastomosis. In the PD group, morbidity rate was 60%, caused by pancreatic leakage, with an incidence of 48%, hemorrhagic complication, occurred in 10% of patients following surgical procedure and infectious complication, with an incidence of 15%. After distal pancreatectomy we recorded 80, 7% no complications, 3, 9% leakage, 15, 4% hemoperitoneum. By multivariate analysis bleeding complications, biliary anastomosis leakage, and infectious complications were consequences of pancreatic leakage (P = 0.025, P = 0.025, and P = 0.025, respectively). A significant statistical difference was recorded analyzing re-operation rates between closure of the main duct with linear stapler versus temporary occlusion of the main duct with neoprene glue (t = 0.049) and closure of the main duct with linear stapler versus duct-to-mucosa anastomosis (t = 0.003). On the ground of our results of bleeding complication, biliary anastomosis leakage and infectious complication were consequences of pancreatic leakage: failure of a surgical anastomosis has serious consequences, particularly in case of anastomosis of the pancreas to the small bowel, because of the digestive capacities of activated pancreatic secretions.

Treatment of Pancreatic Pseudocysts, Pancreatic Necrosis, and Pancreatic Duct Leaks

Pancreatic pseudocysts arise as a complication of acute and chronic pancreatitis or pancreatic trauma (including postsurgical). Pancreatic necrosis occurs following severe pancreatitis and may evolve into an entity termed organized pancreatic necrosis that is endoscopically treatable. Pancreatic duct leaks are frequently seen in relation to pseudocysts and necrosis. Alternatively, pancreatic duct leaks may present with pleural effusions, ascites, or after pancreatic surgery or percutaneous drainage. Endoscopic treatment of pancreatic fluid collections and pancreatic duct leaks can be achieved using transpapillary and/or transmural stent placement.

Mechanical Lithotripsy of Pancreatic and Biliary Stones: Complications and Available Treatment Options Collected From Expert Centers

PD and common bile duct (CBD) stones often require mechanical lithotripsy (ML) at ERCP for successful extraction. The frequency and spectrum of complications is not well described in the literature. To describe the frequency and spectrum of complications of ML. A comprehensive retrospective review of cases requiring ML of large or resistant PC and/or CBD stones using a 46-point data questionnaire on type(s) of complication, treatment attempted, and success of treatment. The study involved 7 tertiary referral centers with 712 ML cases (643 biliary and 69 pancreatic). Overall incidence of complications were: 4-4% (31/712); 23/643 biliary, 8/69 pancreatic; 21 single, 10 multiple. Biliary complications: trapped (TR)/broken (BR) basket (N = 11), wire fracture (FX) (N = 8), broken (BR) handle (N = 7), perforation/duct injury (N = 3). Pancreatic complications: TR/BR basket (N = 7), wire FX (N = 4), BR handle (N = 5), pancreatic duct leak (N = 1). Endoscopic intervention successfully treated complications in 29/31 cases (93.5%). Biliary group treatments: sphincterotomy (ES) extension (N = 7), electrohydraulic lithotripsy (EHL) (N = 11), stent (N = 3), per-oral Soehendra lithotripsy (N = 8), surgery (N = 1), extracorporeal lithotripsy (N = 5), and dislodge stones/change basket (N = 4). Pancreatic group treatments: ES extension (N = 3), EHL (N = 2), stent (N = 5), Soehendra lithotriptor (N = 4), dislodge stones/change basket (N = 2), extracorporeal lithotripsy (ECL) (N = 1), surgery (N = 1). Perforated viscus patient died at 30 days. The majority of ML in expert centers involved the bile duct. The complication rate of pancreatic ML is threefold greater than biliary lithotripsy. The most frequent complication of biliary and pancreatic ML is trapped/broken baskets. Extension of ES and EHL are the most frequently utilized treatment options.

Permanent closure of a pancreatic duct leak by endoscopic coiling

Permanent closure of a pancreatic duct leak by endoscopic coiling

Outcomes analysis of laparoscopic resection of pancreatic neoplasms

Experience with laparoscopic resection of pancreatic neoplasms remains limited. The purpose of this study is to critically analyze the indications for and outcomes after laparoscopic resection of pancreatic neoplasms. The medical records of all patients undergoing laparoscopic resection of pancreatic neoplasms from July 2000 to February 2006 were reviewed. Data are expressed as mean +/- standard deviation. Laparoscopic pancreatic resection was performed in 22 patients (M:F, 8:14) with a mean age of 56.3 +/- 15.1 years and mean body mass index (BMI) of 26.3 +/- 4.5 kg/m2. Nine patients had undergone previous intra-abdominal surgery. Indications for pancreatic resection were cyst (1), glucagonoma (1), gastrinoma (2), insulinoma (3), metastatic tumor (2), IPMT (4), nonfunctioning neuroendocrine tumor (3), and mucinous/serous cystadenoma (6). Mean tumor size was 2.4 +/- 1.6 cm. Laparoscopic distal pancreatectomy was attempted in 18 patients and completed in 17, and enucleation was performed in 4 patients. Laparoscopic ultrasound (n = 10) and a hand-assisted technique (n = 4) were utilized selectively. Mean operative time was 236 +/- 60 min and mean blood loss was 244 +/- 516 ml. There was one conversion to an open procedure because of bleeding from the splenic vein. The mean postoperative LOS was 4.5 +/- 2.0 days. Seven patients experienced a total of ten postoperative complications, including a urinary tract infection (UTI) (1), lower-extremity deep venous thrombosis (DVT) and pulmonary embolus (1), infected peripancreatic fluid collection (1), pancreatic pseudocyst (1), and pancreatic fistula (6). Five pancreatic fistulas were managed by percutaneous drainage. The reoperation rate was 4.5% and the overall pancreatic-related complication rate was 36.4%. One patient developed pancreatitis and a pseudocyst 5 months postoperatively, which was managed successfully with a pancreatic duct stent. There was no 30-day mortality. Laparoscopic pancreatic resection is safe and feasible in selected patients with pancreatic neoplasms. With a pancreatic duct leak rate of 27%, this problem remains an area of development for the minimally invasive technique.