Pancreaticocutaneous Fistula Research Articles

Percutaneous debridement and washout of walled-off abdominal abscess and necrosis using flexible endoscopy: a large single-center experience.

Background and study aims: Direct percutaneous endoscopic necrosectomy has been described as a minimally invasive intervention for the debridement of walled-off pancreatic necrosis (WOPN). In this retrospective cohort study, we aimed to confirm these findings in a US referral center and evaluate the clinical value of this modality in the treatment of pancreatic necrosis as well as other types of intra-abdominal fluid collections and necrosis. Patients and methods: Twelve consecutive patients with WOPN or other abdominal abscess requiring debridement and washout underwent computed tomography (CT)-guided drainage catheter placement. Each patient then underwent direct percutaneous endoscopic necrosectomy and washout with repeat debridement performed until complete. Drains were then removed once output fell below 30 mL/day and imaging confirmed resolution. The primary endpoints were time to clinical resolution and sustained resolution at 1-year follow up. Results: Ten patients were treated for WOPN, one for necrotic hepatic abscesses, and one for omental necrosis. The median time to intervention was 85 days with an average of 2.3 necrosectomies performed. Complete removal of drains was accomplished in 11 patients (92 %). The median time to resolution was 57 days. No serious adverse events occurred; however, one patient developed pancreaticocutaneous fistulas. Ten patients completed 1-year surveillance of which none required drain replacement. No patients required surgery or repeat endoscopy. Conclusions: This series supports the premise that direct percutaneous endoscopic necrosectomy is a safe and effective intervention for intra-abdominal fluid collections and necrosis in appropriately selected patients. Our study demonstrates a high clinical success rate with minimal adverse events. This modality offers several potential advantages over surgical and transgastric approaches including use of improved accessibility, an excellent safety profile, and requirement for only deep or moderate sedation.

EUS-guided transgastric drainage of a peripancreatic collection containing an arterial bypass graft

A 63-year-old man was admitted with aortic dissection and acute thrombosis of the superior mesenteric artery in May 2013. After urgent surgical arterial bypass, he experienced postoperative mesenteric ischemia, pancreatitis, and bleeding, requiring 2 additional surgical interventions. Subsequently, he experienced pancreaticocutaneous fistula and abdominal sepsis; after a lengthy hospital stay, he was discharged in September. One day after discharge he was readmitted for fever related to Pseudomona and Serratia spp infection of a peribypass collection, which was treated with percutaneous drainage twice, and 4 courses of antibiotics for recurrent bacteriemia until April 2014, when recurrence of the peribypass collection was diagnosed. Because of the patient’s unacceptable surgical risk, EUS-guided transgastric drainage of the collection with the arterial bypass floating inside (Fig. 1) was completed (Video 1, available online at www.giejournal. org). A double pigtail stent was inserted, followed by a nasocystic catheter for continuous lavage during 1 week. After 4 weeks, a CT scan confirmed resolution of the collection, and the transgastric double-pigtail stent was retrieved uneventfully. He has been asymptomatic except for an episode of fever, which resolved with antibiotics without recurrence of fluid collection during 9 months of follow-up.

Targeted Transgastric Drainage of Isolated Pancreatic Duct Segments to Cure Persistent Pancreaticocutaneous Fistulas from Pancreatitis

Chronic pancreaticocutaneous fistulas can be difficult to treat. This article presents a snare-target technique for draining a nondilated pancreatic duct into the stomach, diverting pancreatic fluid away from the pancreaticocutaneous fistula to allow it to heal. Internal or internal/external transgastric pancreatic duct or fistula drains were placed in six patients. After an average of 4 months of drainage, all six patients experienced resolution of the cutaneous fistula. Two patients developed a pseudocyst but no recurrent fistula after drain removal, and the other four patients had no pseudocyst or fistula after an average 27-month follow-up (range, 6–74 mo).

EUS-Guided Pancreatic Intervention For Treatment Of Pancreaticocutaneous Fistulas

Introduction: To evaluate experience with endoscopic ultrasound (EUS)-guided treatment of pancreaticocutaneous fistulas (PCFs) at a tertiary referral center. Methods: Retrospective review of patients who underwent EUS-guided management of PCFs. Demographic, clinical, imaging, procedural, and outcome variables were abstracted. Results: Four patients (3 female, age range 30-71 years) presented with PCFs. In all cases the fistula was due to an obstructed and leaking pancreatic duct in tail: 3 developed PCFs after Whipple procedure for malignancy (n=2) or an inflammatory mass (n=1), and the fourth developed a PCF following percutaneous drainage of a pancreatic fluid collection in the setting of severe acute pancreatitis with disconnected pancreatic duct syndrome. Mean duration of the fistula was 189 days (range: 80-233). PCFs persisted despite trials of nil by mouth with TPN (n=1), octreotide therapy (n=2), and failed attempts at ERCP (n=4). The mean output was 350 cc/day (range: 200-500 cc), and mean amylase concentration was 15,866 U/L. Patients underwent EUS-guided transmural puncture of the pancreatic duct (n=2), fistula track (n=1), or both (n=1), with placement of 1 or 2 plastic transmural stents providing internal drainage to the stomach (n=3) or duodenum (n=1). Patients underwent a mean of 1.75 endoscopic procedures (range: 1-2), with placement of additional stents in the transmural track during the second procedure, as well as transmural drainage of an additional site of pancreatic duct leakage in 1 patient. Drainage from PCFs ceased after the first endoscopic intervention in 3 patients and after the second procedure in the fourth patient, and all percutaneous drains were removed. Stents were left in place indefinitely. One patient was lost to follow-up; mean follow-up for the remainder was 226 days (range: 170-410). In all 3 cases there has been no recurrence of PCFs, and no patient developed symptoms of pancreatitis, pancreatic fluid collections, or hyperglycemia requiring medical therapy. Weight stabilized or increased in all, and PCF-related pain resolved. Follow-up CT or MR performed in all patients after PCF drain removal showed no pancreatitis or fluid collections. Conclusion: EUS-guided pancreatic duct intervention may successfully treat pancreaticocutaneous fistulas, allowing removal of percutaneous drains. EUS-guided therapy is an attractive alternative for patients who might otherwise require pancreatic tail resection or completion pancreatectomy to achieve resolution of a PCF.

Pure pancreaticocutaneous fistula shunted into the urinary bladder. Lesson learned by an incomplete, original attempt.

Because pancreaticocystostomy is a method of exocrine secretion management in pancreas transplantation, a legitimate question is whether a pure pancreatic fistula could be shunted into the bladder. After duodenopancreatectomy for cancer, a pancreaticojejunostomy leakage was treated by pancreas-saving anastomosis disconnection. The resulting pure pancreaticocutaneous fistula was later diverted into the bladder using a Denver valved-pump device. Technical problems necessitated redoing the shunt using a modified technique and device. Although the system did work, catheter displacement outside the bladder finally caused device takedown and external fistula restoration. Our attempt did not succeed mostly because of our inexperience in dealing with an altogether novel issue without appropriate technology. Supposing its feasibility, a pancreatic-bladder shunt might have a role in treating pure pancreatic fistulas or creating an external fistula whenever the pancreatic remnant is unreliable for an anastomosis, or when a leaked anastomosis' disconnection is preferable to completion pancreatectomy.

4:24 PM; Abstract No. 77 - Targeted transgastric drainage of persistent pancreaticocutaneous fistulas

4:24 PM; Abstract No. 77 - Targeted transgastric drainage of persistent pancreaticocutaneous fistulas

Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: Long-term clinical outcomes

Background Management options for symptomatic and infected walled-off pancreatic necrosis (WOPN) have evolved over the past decade from open surgical necrosectomy to more minimally invasive approaches. We reported the use of a combined percutaneous and endoscopic approach (dual modality drainage [DMD]) for the treatment of symptomatic and infected WOPN, with good short-term outcomes in a small cohort of patients. Objective To describe the long-term outcomes of 117 patients with symptomatic and infected WOPN treated by DMD. Design Review of a prospective, internal review board–approved database. Setting Single, North American, tertiary-care center. Patients All patients with symptomatic and infected WOPN treated by DMD at our institution between 2007 and 2012. Intervention DMD of symptomatic and infected WOPN. Main Outcome Measurements Disease-related mortality, pancreaticocutaneous fistula formation, need for early and late surgical intervention, procedure-related adverse events. Results A total of 117 patients underwent DMD for symptomatic and infected WOPN. A total of 103 have completed treatment, with all percutaneous drains removed. Ten patients are still undergoing treatment, and 4 patients died with percutaneous drains in place (3.4% disease-related mortality). For the patients completing therapy, the median duration of follow-up was 749.5 days. No patients required surgical necrosectomy or surgical treatment of DMD-related adverse events; 3 patients required late surgery for pain (n = 2) and gastric outlet obstruction (n = 1). There were no procedure-related deaths. In patients who have completed treatment, percutaneous drains have been removed in 100%; no patients have developed pancreaticocutaneous fistulas. Limitations Single-center design, lack of a comparison group. Conclusion DMD for symptomatic and infected WOPN results in favorable clinical outcomes; complete avoidance of pancreaticocutaneous fistulae, surgical necrosectomy, and major procedure-related adverse events, while maintaining single-digit disease-related mortality.

Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711

BackgroundInfected necrotising pancreatitis is a potentially lethal disease that nearly always requires intervention. Traditionally, primary open necrosectomy has been the treatment of choice. In recent years, the surgical step-up approach, consisting of percutaneous catheter drainage followed, if necessary, by (minimally invasive) surgical necrosectomy has become the standard of care. A promising minimally invasive alternative is the endoscopic transluminal step-up approach. This approach consists of endoscopic transluminal drainage followed, if necessary, by endoscopic transluminal necrosectomy. We hypothesise that the less invasive endoscopic step-up approach is superior to the surgical step-up approach in terms of clinical and economic outcomes.Methods/DesignThe TENSION trial is a randomised controlled, parallel-group superiority multicenter trial. Patients with (suspected) infected necrotising pancreatitis with an indication for intervention and in whom both treatment modalities are deemed possible, will be randomised to either an endoscopic transluminal or a surgical step-up approach. During a 4 year study period, 98 patients will be enrolled from 24 hospitals of the Dutch Pancreatitis Study Group. The primary endpoint is a composite of death and major complications within 6 months following randomisation. Secondary endpoints include complications such as pancreaticocutaneous fistula, exocrine or endocrine pancreatic insufficiency, need for additional radiological, endoscopic or surgical intervention, the need for necrosectomy after drainage, the number of (re-)interventions, quality of life, and total direct and indirect costs.DiscussionThe TENSION trial will answer the question whether an endoscopic step-up approach reduces the combined primary endpoint of death and major complications, as well as hospital stay and related costs compared with a surgical step-up approach in patients with infected necrotising pancreatitis.

Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: long-term clinical outcomes

Management options for symptomatic and infected walled-off pancreatic necrosis (WOPN) have evolved over the past decade from open surgical necrosectomy to more minimally invasive approaches. We reported the use of a combined percutaneous and endoscopic approach (dual modality drainage [DMD]) for the treatment of symptomatic and infected WOPN, with good short-term outcomes in a small cohort of patients. To describe the long-term outcomes of 117 patients with symptomatic and infected WOPN treated by DMD. Review of a prospective, internal review board-approved database. Single, North American, tertiary-care center. All patients with symptomatic and infected WOPN treated by DMD at our institution between 2007 and 2012. DMD of symptomatic and infected WOPN. Disease-related mortality, pancreaticocutaneous fistula formation, need for early and late surgical intervention, procedure-related adverse events. A total of 117 patients underwent DMD for symptomatic and infected WOPN. A total of 103 have completed treatment, with all percutaneous drains removed. Ten patients are still undergoing treatment, and 4 patients died with percutaneous drains in place (3.4% disease-related mortality). For the patients completing therapy, the median duration of follow-up was 749.5 days. No patients required surgical necrosectomy or surgical treatment of DMD-related adverse events; 3 patients required late surgery for pain (n = 2) and gastric outlet obstruction (n = 1). There were no procedure-related deaths. In patients who have completed treatment, percutaneous drains have been removed in 100%; no patients have developed pancreaticocutaneous fistulas. Single-center design, lack of a comparison group. DMD for symptomatic and infected WOPN results in favorable clinical outcomes; complete avoidance of pancreaticocutaneous fistulae, surgical necrosectomy, and major procedure-related adverse events, while maintaining single-digit disease-related mortality.

Tu1535 New Toys or Old? Comparing Approaches to EUS-Guided Trans-Enteric Stent Placement Into Symptomatic Walled-off Pancreatic Necrosis

Dual modality drainage (DMD) of symptomatic walled-off pancreatic necrosis (WOPN) involves the initial placement of a percutaneous drainage catheter followed immediately by the endoscopic placement of two trans-enteric stents into the necroma. The endoscopic portion of the procedure is typically performed under endoscopic ultrasound (EUS) control. Our group has recently shown this approach to be successful in avoiding both surgery and the development of pancreatico-cutaneous fistulae while maintaining single-digit mortality rates.

Sp820 Combined Endoscopic and Percutaneous Rendezvous Internalization of Chronic Pancreatico-cutaneous Fistulae

Sp820 Combined Endoscopic and Percutaneous Rendezvous Internalization of Chronic Pancreatico-cutaneous Fistulae

Endoscopic ultrasound-guided drainage of pancreatic fluid collections

Pancreatic fluid collections (PFCs) develop secondary to either fluid leakage or liquefaction of pancreatic necrosis following acute pancreatitis, chronic pancreatitis, surgery or abdominal trauma. Pancreatic fluid collections include acute fluid collections, acute and chronic pancreatic pseudocysts, pancreatic abscesses and pancreatic necrosis. Before the introduction of linear endoscopic ultrasound (EUS) in the 1990s and the subsequent development of endoscopic ultrasound-guided drainage (EUS-GD) procedures, the available options for drainage in symptomatic PFCs included surgical drainage, percutaneous drainage using radiological guidance and conventional endoscopic transmural drainage. In recent years, it has gradually been recognized that, due to its lower morbidity rate compared to the surgical and percutaneous approaches, endoscopic treatment may be the preferred first-line approach for managing symptomatic PFCs. Endoscopic ultrasound-guided drainage has the following advantages, when compared to other alternatives such as surgical, percutaneous and non-EUS-guided endoscopic drainage. EUS-GD is less invasive than surgery and therefore does not require general anesthesia. The morbidity rate is lower, recovery is faster and the costs are lower. EUS-GD can avoid local complications related to percutaneous drainage. Because the endoscope is placed adjacent to the fluid collection, it can have direct access to the fluid cavity, unlike percutaneous drainage which traverses the abdominal wall. Complications such as bleeding, inadvertent puncture of adjacent viscera, secondary infection and prolonged periods of drainage with resultant pancreatico-cutaneous fistulae may be avoided. The only difference between EUS and non-EUS drainage is the initial step, namely, gaining access to the pancreatic fluid collection. All the subsequent steps are similar, i.e., insertion of guide-wires with fluoroscopic guidance, balloon dilatation of the cystogastrostomy and insertion of transmural stents or nasocystic catheters. With the introduction of the EUS-scope equipped with a large operative channel which permits drainage of the PFCs in "one step", EUS-GD has been increasingly carried out in many tertiary care centers and has expanded the safety and efficacy of this modality, allowing access to and drainage of overly challenging fluid collections. However, the nature of the PFCs determines the outcome of this procedure. The technique and review of current literature regarding EUS-GD of PFCs will be discussed.

Su1436 Combined Endoscopic Nasopancreatic and Percutaneous Drainage to Treat Pancreaticopleural Fistulae

Pancreaticopleural fistulae occur as a rare complication of acute or chronic pancreatitis and present as a high-amylase pleural effusion. Several reports demonstrated the efficacy of endotherapy with transpapillary stenting but the experience of endoscopic nasopancreatic drain (ENPD) placement is limited. The data with regard to the usefulness and safety of percutaneous drainage in combination with ENPD for treating pancreatic pleural effusion is also limited. The aim of the present study was to evaluate the efficacy and safety of combined ENPD placement and percutaneous approach to treat pancreaticopleural fistulae. From July 2008 to August 2010, six patients (age range: 23-68 years, 4 men and 2 women) with pancreatic pleural effusion with pancreatic duct disruption documented on pancreatogram were studied. All patients were treated by endoscopic pancreatic sphincterotomy, ENPD (5Fr) placement, and percutaneous drainage (8.5Fr). Main Outcome Measurements: Resolution of pancreaticopleural fistula and pancreatic pleural effusion, and development of chronic pancreaticocutaneous fistulae and ENPD-induced ductal strictures. Results: Of the six patients, four had alcoholic acute pancreatitis, one had alcoholic chronic pancreatitis, and one was associated with post-operative pancreatic trauma after splenectomy. The healing of pancreaticopleural fistulae was demonstrated by nasopancreatogram in 10-23 days (median 15 days) in all patients. The resolution of pancreatic pleural effusion was demonstrated as early as 10 days of combined modality. ENPD and percutaneous drain could be removed without another procedure. No patients had development of major complications including chronic pancreaticocutaneous fistulae and ENPD-induced ductal strictures. There was no recurrence of pancreatic pleural effusion at a mean follow up of 10 months. Pancreaticopleural fistulae can be treated by combined ENPD placement and percutaneous drainage effectively, avoiding repeated endoscopic retrograde pancreatography and development of pancreaticocutaneous fistulae and ENPD-induced ductal strictures.

Successful transgastric pancreaticography and endoscopic ultrasound-guided drainage of a disconnected pancreatic tail syndrome

We aim to demonstrate that endoscopic ultrasound (EUS)-guided transgastric pancreaticography/drainage of the pancreatic duct is feasible and successful in healing a persisting pancreaticocutaneous fistula. By means of a case report, we describe the following alternative therapeutic procedure. A 76-year-old male had: (1) 10 surgical interventions because of necrotizing acute pancreatitis with a persisting pancreaticocutaneous fistula (volume 200-300 ml/day); (2) an unsuccessful attempt of transpapillary drainage (disrupted duct after necrosectomy). He then underwent a EUS-guided transluminal pancreaticography/drainage of the pancreatic duct. A transgastric puncture was performed followed by, insertion of a guide wire into the dilated tail segment, and expansion of the gastropancreaticostomy using a 10-Fr retriever. A 10-Fr Amsterdam prosthesis was then placed through the guide wire. The procedure was both a technical and clinical success as indicated by fistula occlusion and sufficient internal drainage of the pancreatic juice via the gastropancreaticostomy. No severe complications such as bleeding, perforation stent occlusion or migration were observed during the 15-month follow-up. Transgastric pancreaticography and EUS-guided drainage of the enlarged pancreatic duct are elegant and feasible alternative options for the treatment of specific pancreatic lesions such as persisting pancreaticocutaneous fistula (complication after necrotizing pancreatitis), after pancreatic resective surgery, chronic pancreatitis and anomaly of the congenital pancreatic or postoperative gastrointestinal anatomy. Moreover, the procedure may represent a valid tool to avoid surgery and more invasive interventions.

Laparoscopic Treatment of a Pancreaticocutaneous Fistula

Pancreaticocutaneous fistulas are a frequent complication of pancreatic surgery. Traditionally, they have been surgically treated with either partial pancreatectomy or fistuloenterostomy. We report the minimally invasive management of a pancreaticocutaneous fistula with laparoscopic fistulogastrostomy.

Nonsurgical Treatment of Organized Pancreatic Necrosis

Surgical necrosectomy in patients with pancreatic necrosis has been associated with pancreaticocutaneous fistula formation. To determine whether percutaneous drainage followed immediately by endoscopic abscess drainage could prevent fistula formation and eliminate the need for surgical necrosectomy, investigators conducted a retrospective study involving 15 patients with organized pancreatic necrosis who underwent this combined-modality drainage technique at a single tertiary care center. Necromas occurred within 2 cm of the gastric or duodenal lumen in all patients and were located in the entire pancreas in …

Combined endoscopic and percutaneous drainage of organized pancreatic necrosis

Severe acute pancreatitis is often complicated by organized necrosis, which can lead to abscess formation and clinical deterioration. We sought to devise a combined endoscopic and percutaneous approach to drainage of organized pancreatic necrosis, with the primary goal of preventing the formation of chronic pancreaticocutaneous fistulae, and secondary goals of avoiding the need for surgical necrosectomy and reducing endoscopic resource utilization. Retrospective review of an institutional review board-approved database. Single North American tertiary referral center. Patients with severe acute pancreatitis complicated by organized necrosis requiring drainage. CT-guided percutaneous drain, followed immediately by endoscopic transenteric drainage. Development of chronic pancreaticocutaneous fistulae, number of endoscopic procedures requiring follow-up drainage, need for surgical necrosectomy, procedure-related morbidity, and mortality. Fifteen patients (12 males, 3 females; mean age, 58 years) underwent combined modality drainage. All procedures were technically successful. Immediate complications included fever and hypotension (n = 2); late complications included parenchymal infection after drain removal (n = 1). Twenty-five total endoscopies (4 for drain manipulation) were performed in the cohort subsequent to the initial drainage. After a median duration of follow-up of 189 days, percutaneous drains were removed in all 13 patients in whom this was attempted; no patients had development of chronic pancreaticocutaneous fistulae. There were no deaths, and no patients required surgery. Highly selected patient population, lack of comparison group, single-center experience. In some highly selected patients with infected or symptomatic organized pancreatic necrosis, combined modality drainage results in favorable clinical outcomes with low associated, procedure-related morbidity. Pancreaticocutaneous fistulae and surgical necrosectomy were avoided with minimal endoscopic resource utilization.

Pancreatobiliary Complications After Composite Visceral Transplantation: Incidence, Diagnosis and Management

Background: Combined liver-intestinal (L/SB) and multivisceral (MV) transplantation has been increasingly utilized with significant improvement in outcome. This is the first report to address the potential risk and management of pancreatobiliary (PB) complications in this unique population. Aim: Assess incidence, clinical features and management outcome of PB complications after the different types of the composite visceral graft. Methods: Between May 1990 and October 2006, a total of 227 consecutive patients received a composite visceral graft. Of these, 115 (51%) were adults and 112 (49%) were children. The composite visceral grafts were L/SB in 130 (57%) and MV in the remaining 97 (43%). The pancreas was included in 61 (53%) of the L/SB and the liver was excluded in 25 (26%) of the MV. Most donors were ABO identical and HLA matching was random with positive cross match in 23%. Immunosuppression was tacrolimus based and induction was used in 150 patients (66%). With a mean cold ischemia time of 9 ± 2 hours, UW solution was used to preserve the allograft in 82% and HTK in 18%. With ERCP being the gold standard for the diagnosis of biliary complications and pancreatic leak, significant injury of the pancreatic gland was diagnosed according to serum tests and operative findings. Results: A total of 28 PB complications were diagnosed in 20 patients with an overall incidence of 9%. Risk was similar among L/SB and MV recipients with a rate of 8% and 10%, respectively. Of the 28 morbid events, 9 were biliary complications alone, 11 were isolated pancreatic injury and 8 were combined pathology. Biliary complications included bile leak (n = 5), bile cast syndrome (n = 4), ampullary dysfunction (n = 3) and recurrent ascending cholangitis (n = 1). Pancreatic injury was necrotizing pancreatitis in 7, distal duct fistulae in 6 and chronic calcific pancreatitis in 2. ERCP was instrumental in diagnosis and treatment of cases with ampullary dysfunction, bile cast syndrome and non-surgical PB leak. However, surgical intervention was performed in patients with significant pancreatic allograft necrosis and anastomotic biliary leak. With no direct complication related mortality, all morbid events were successfully treated with the exception of a case with persistent pancreatico-cutaneous fistula. With no statistically identifiable risk factors, there was a trend toward more pancreatitis events with HTK use. Conclusions: PB complications are not uncommon after composite visceral transplantation. Early diagnosis and prompt intervention with combined surgical and endoscopic approach is essential for proper management and successful outcome.

EUS-Guided Pancreaticoduodenostomy: A New Technique for Main Pancreatic Duct Drainage in Acute and Chronic Pancreatitis

Background: Endoscopic drainage of the main pancreatic duct (MPD) in chronic pancreatitis (CP) can lead to a decrease in ductal hypertension, resulting in pain relief. Moreover, MPD drainage can be helpful in acute pancreatitis (AP) complicated with pancreatic duct disruption (PDD), in order to decrease the leakage of pancreatic juice from the disconnected pancreatic segment. However, in case of complete MPD obstruction (CP) or complete PDD (AP), transpapillary access to the proximal MPD segment cannot be obtained and conventional endoscopic ductal drainage is not possible. In these cases, a new technique, EUS-guided pancreaticoduodenostomy (PD), can be useful. Patients and Methods: We report five patients with CP (n = 4) or AP (n = 1) who underwent EUS-guided PD in order to achieve MPD drainage. In all patients, cannulation of the proximal segment of the MPD was not possible by means of a transpapillary approach. Results: Four patients with painful CP presented severe ductal dilation above a tight distal stricture. The remaining patient had presented severe AP, complicated with complete PDD and a pancreaticocutaneous fistula secondary to a previous percutaneous collection drainage. The proximal segment of the MPD was dilated in all patients. PD was performed as follows: Under EUS-guidance, a 19 gauge needle was inserted transduodenally into the proximal, dilated MPD, after its visualization with the tip of the echo-endoscope positioned in the duodenal bulb. Contrast medium was injected, confirming correct location of the needle in the duct. The needle was then exchanged over a guidewire for a 6.5 F diathermic sheath, introduced in the pancreaticoduodenal channel using cutting current. This channel was further enlarged by balloon dilation in two patients. Finally, a pancreaticoduodenal plastic straight stent was placed. In both patients who had previous balloon dilation of the PD, a 10 F stent was placed, whereas smaller diameter stents (6 F or 7 F) were initially used in the remaining patients. These stents were replaced by 10F stents during a second procedure. No complications were recorded. All patients had initial symptom resolution (pain relief and fistula closure) and remained well during a mean follow-up of 10 months (range: 3-30) with the stent in place. Conclusions: EUS guided PD is a new method of ductal decompression in patients with CP or AP, in cases when conventional ERCP fails to obtain access to the proximal MPD. Background: Endoscopic drainage of the main pancreatic duct (MPD) in chronic pancreatitis (CP) can lead to a decrease in ductal hypertension, resulting in pain relief. Moreover, MPD drainage can be helpful in acute pancreatitis (AP) complicated with pancreatic duct disruption (PDD), in order to decrease the leakage of pancreatic juice from the disconnected pancreatic segment. However, in case of complete MPD obstruction (CP) or complete PDD (AP), transpapillary access to the proximal MPD segment cannot be obtained and conventional endoscopic ductal drainage is not possible. In these cases, a new technique, EUS-guided pancreaticoduodenostomy (PD), can be useful. Patients and Methods: We report five patients with CP (n = 4) or AP (n = 1) who underwent EUS-guided PD in order to achieve MPD drainage. In all patients, cannulation of the proximal segment of the MPD was not possible by means of a transpapillary approach. Results: Four patients with painful CP presented severe ductal dilation above a tight distal stricture. The remaining patient had presented severe AP, complicated with complete PDD and a pancreaticocutaneous fistula secondary to a previous percutaneous collection drainage. The proximal segment of the MPD was dilated in all patients. PD was performed as follows: Under EUS-guidance, a 19 gauge needle was inserted transduodenally into the proximal, dilated MPD, after its visualization with the tip of the echo-endoscope positioned in the duodenal bulb. Contrast medium was injected, confirming correct location of the needle in the duct. The needle was then exchanged over a guidewire for a 6.5 F diathermic sheath, introduced in the pancreaticoduodenal channel using cutting current. This channel was further enlarged by balloon dilation in two patients. Finally, a pancreaticoduodenal plastic straight stent was placed. In both patients who had previous balloon dilation of the PD, a 10 F stent was placed, whereas smaller diameter stents (6 F or 7 F) were initially used in the remaining patients. These stents were replaced by 10F stents during a second procedure. No complications were recorded. All patients had initial symptom resolution (pain relief and fistula closure) and remained well during a mean follow-up of 10 months (range: 3-30) with the stent in place. Conclusions: EUS guided PD is a new method of ductal decompression in patients with CP or AP, in cases when conventional ERCP fails to obtain access to the proximal MPD.

Laparoscopic approach for solitary insulinoma: a multicentre study

Surgical resection of insulinomas is the preferred treatment in order to avoid symptoms of hypoglycaemia. During the past years, advances in laparoscopic techniques have allowed surgeons to approach the pancreas and treat these lesions laparoscopically. We analysed the feasibility, safety, and outcome of patients undergoing laparoscopic resection of insulinomas in a large, retrospective, multicentre study. Thirty-six patients with pancreatic insulinomas were enrolled in this study. All patients were suspected of having solitary insulinomas after preoperative localisation tests and underwent a laparoscopic approach. Patients, operating characteristics and outcome were analysed. Mean patient age was 48 years (range 20-77 years). Insulinomas were localised in the head (n=7), isthmus (n=2), body (n=14) or tail (n=13) of the pancreas before laparoscopic approach. Mean size of the lesions was 15.5 mm (range 4-25 mm). The surgical procedure was enucleation in 19 cases (52%), spleen-preserving distal pancreatectomy in 12 cases (33%), spleno-pancreatectomy in three cases (8%), one duodenopancreatectomy and one central pancreatectomy. Conversion rate was 30%. The reason for conversion in seven patients (63%) was the inability to localise the tumour during the laparoscopic procedure. In six of these cases laparoscopic ultrasonography was not performed. Mean operating time was 156 min (range 50-420 min). Postoperative course was uneventful in 23 patients (64%). Eleven patients (30%) developed specific complications of pancreatic surgery: intra-abdominal abscess (n=6) or pancreatico-cutaneous fistula (n=5). Mean duration of fistulae was 55 days (range 5-130 days) and all the fistulae were dry at follow-up. After a mean follow-up period of 26 months (range 2-87 months), 33 patients (91%) are free of symptoms, and three patients have been lost to follow-up. The laparoscopic approach is safe to treat preoperatively localised insulinoma, with a morbidity rate comparable to that for the open approach. When the tumour is not found during laparoscopy, laparoscopic ultrasonography seems to be the most efficient tool to localise it and probably to prevent conversion.