Transpapillary stenting for pancreaticocutaneous fistulas

Evolution of Pancreatic Endotherapy

In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.

Acute obstructive suppurative pancreatic ductitis in pancreatic malignancies

Background and study aims  Acute obstructive suppurative pancreatic ductitis (AOSPD) is a suppurative pancreatic duct infection with main pancreatic duct (MPD) or accessory pancreatic duct obstruction in the absence of a pancreatic pseudocyst or necrosis, which is experienced usually in chronic pancreatitis. The diagnosis is confirmed by the finding of pancreatic duct obstruction on endoscopic retrograde cholangiopancreatography (ERCP) with evidence of infection, such as a positive pancreatic juice culture or drainage of purulent pancreatic juice. Patients and methods  We studied five patients with pancreatic ductal adenocarcinoma (PDAC) and one with chronic myelogenous leukemia (CML), who suffered from AOSPD. Results  Of the 281 PDAC and 39 CML patients who we treated in the past 2 years in our hospital, five with PDAC (1.8 %) and one with CML (2.6 %) experienced AOSPD. Each patient had fever, abdominal pain, and increased blood C-reactive protein. Pancreatography found that each patient had a MPD stricture and an upstream dilatation. Four had a disruption of the MPD in the upper stream of the stricture. Nasopancreatic drainage was successfully performed in all patients. Pancreatic juice culture was positive for Klebsiella pneumonia, Enterobacter agerogenes, or Enterococcus cloacae in four patients. Conclusion  AOSPD should be considered in pancreatic malignancy with fever and abdominal pain. Prompt diagnosis of AOSPD could avoid shortening of survival of patients with an already poor prognosis by infection.

Endoscopic treatment of refractory external pancreatic fistulae with disconnected pancreatic duct syndrome

BACKGROUND

External pancreatic fistulae (EPF) developing in setting of disconnected pancreatic duct syndrome (DPDS) are associated with significant morbidity and surgery is the only effective treatment.

AIM

To describe safety and efficacy of various endoscopic including endoscopic ultrasound (EUS) guided drainage techniques for resolving EPF in DPDS.

METHODS

Retrospective analysis of data base of 18 patients (15 males; mean age: 37.6 ± 7.1years) with EPF and DPDS who were treated with various endoscopic techniques including EUS guided transmural drainage.

RESULTS

EPF developed post percutaneous drainage (PCD) (n = 15) or post-surgical necrosectomy (n = 3) of acute necrotic collections. All patients had refractory EPF with daily output of >50 ml/day with mean duration being 19.2 ± 6.1 weeks. One patient had failed surgical fistulo-jejunostomy. Various endoscopic techniques used were: transmural placement of pigtail stent through gastric opening of trans-gastric PCD (n = 5), EUS guided transmural puncture of fluid collection created by clamping PCD (n = 5) or by instillation of water though PCD (n = 3), direct EUS-guided puncture of fistula tract (n = 1) and EUS guided pancreaticogastrostomy (n = 4). EPF healed in 17/18 (94%) patients within 5-21 days and there has been no recurrence over follow up of 16.7 ± 12.8 weeks. Asymptomatic spontaneous external migration of stents was observed in 5/18 (29.4%) patients.

CONCLUSION

Management of refractory EPFs in setting of DPDS is challenging. In our experience, combination of various endoscopic techniques including EUS guided transmural drainage appears to be safe and effective treatment modality for treating these complex EPF's. However, further studies to identify patient selection and best treatment approaches are needed.

Endoscopic transpapillary drainage in disconnected pancreatic duct syndrome after acute pancreatitis and trauma: long-term outcomes in 31 patients

Background

Conventionally, disconnected pancreatic duct syndrome is treated surgically. Endoscopic management is associated with lesser morbidity and mortality than that observed with surgery and shows similar success rates. However, limited data are available in this context. We evaluated the efficacy of endotherapeutic management for this syndrome.

Methods

We prospectively obtained data of patients with disconnected pancreatic duct syndrome between September 2008 and January 2016. Demographic and clinical data were assessed, and factors affecting clinical outcomes were statistically analyzed.

Results

Thirty-one patients underwent 40 endoscopic transpapillary procedures, and 1 patient developed an infection after prosthesis insertion. Etiological contributors to disconnected pancreatic duct syndrome were abdominal trauma (52%) and acute necrotizing pancreatitis (48%). The median interval between the appearance of pancreatic leaks and disconnected pancreatic duct syndrome was 6.6 months (range 0.5–84 months). The median follow-up after the last treatment procedure was 38 months (range 17–99 months). Patients with complete main pancreatic duct disruption in the body/tail showed a low risk of pancreatic atrophy (P = 0.009). This study highlighted the significant correlation between endoscopic transpapillary drainage and clinical success (P = 0.014).

Conclusions

Disconnected pancreatic duct syndrome is not an uncommon sequel of pancreatic injury, and much of the delayed diagnosis is attributable to a lack of knowledge regarding this disease. Endoscopic transpapillary intervention with ductal stenting is an effective and safe treatment for this condition.

Obstructive pancreatitis secondary to a pancreatic metastasis from lung cancer treated with nasopancreatic drainage

A 44- and a 66-year-old woman underwent nasopancreatic drainage (NPD) to treat obstructive pancreatitis secondary to a pancreatic metastasis from lung cancer. Both patients were diagnosed with stage IV lung cancer and underwent chemotherapy for 17 and 15 months, respectively. Abdominal ultrasonography and computed tomography revealed a solid pancreatic tail tumor measuring 2.5 cm and 1.3 cm in diameter, respectively. Additionally, we observed dilatation of the upstream main pancreatic duct (MPD) and edematous parenchyma with peripancreatic inflammatory changes limited to the pancreatic tail. Both patients were diagnosed with moderately severe acute pancreatitis and received fluid resuscitation, an opioid analgesic, antibiotics, and a protease inhibitor. However, owing to unrelenting pain, we performed endoscopic retrograde cholangiopancreatography (ERCP) for pancreatic duct drainage in both patients. ERCP showed a stricture in the MPD in the pancreatic tail with upstream dilatation. A 5-Fr NPD tube was inserted to drain the dilated MPD, and cloudy pancreatic juice was drained. NPD tube placement led to pain relief in both patients. Pancreatic juice cultures grew Enterococcus faecium and Enterobacter cloacae, respectively. The NPD tube was later cut in both cases using a pair of scissor forceps.

Thoracic complications of pancreatitis

Acute pancreatitis in its severe form may lead to systemic inflammatory response syndrome and multisystem organ dysfunction. Acute lung injury is an important cause of mortality in the setting of severe acute pancreatitis. Besides lung involvement, acute and chronic pancreatitis may also lead to the involvement of other thoracic compartments, including mediastinum, pleura, and vascular structures. These manifestations are an important cause of morbidity and may pose diagnostic and therapeutic challenges. These manifestations have not been discussed in detail in the available literature. In this review, we discuss the thoracic complications of pancreatitis, including lung, pleural, mediastinal, and vascular manifestations.

Acute obstructive suppurative pancreatic ductitis (AOSPD) in pancreatic cancer treated by nasopancreatic drainage

An 80-year-old woman with pancreatic cancer was admitted with fever and abdominal pain. Blood examinations showed an elevated CRP level. On computed tomography (CT), a pancreatic tumor with a dilated upstream main pancreatic duct (MPD) was seen. Endoscopic retrograde cholangiopancreatography (ERCP) showed the strictured part of the MPD at the head of the pancreas with upstream dilatation. A nasopancreatic drainage tube was placed. Through the tube, purulent pancreatic juice was discharged and culture of the pancreatic juice grew Klebsiella pneumoniae. On the day after ERCP, the patient's condition and the laboratory results improved. The patient's disorder was diagnosed as acute obstructive suppurative pancreatitis with pancreatic cancer.

Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification

BACKGROUND

Pancreatic leaks occur as a complication of upper gastrointestinal surgery, acute pancreatitis, or abdominal trauma. Pancreatic fistulas and leaks are primarily managed conservatively. Overall, conservative measures are successful in more than half of cases. Whenever conservative treatment is not efficient, surgery is usually considered the treatment of choice. Nowadays however, endoscopic treatment is being increasingly considered and employed in many cases, as a surgery sparing intervention.

AIM

To introduce a classification of pancreatic fistulas according to the location of the leak and ductal anatomy and finally propose the best suited endoscopic method to treat the leak according to current literature.

METHODS

We performed an extensive review of the literature on pancreatic fistulae and leaks.

RESULTS

In this paper, we review the various types of leaks and propose a novel endoscopic classification of pancreatic fistulas in order to standardize and improve endoscopic treatment.

CONCLUSIONS

A proper and precise diagnosis should be made before embarking on endoscopic treatment for pancreatic leaks in order to obtain prime therapeutic results. A multidisciplinary team of interventional endoscopists, pancreatic surgeons, and interventional radiologists is best suited to care for these patients.

Fistulojejunostomy Versus Distal Pancreatectomy for the Management of the Disconnected Pancreas Remnant Following Necrotizing Pancreatitis

BACKGROUND

A disconnected distal pancreas (DDP) remnant is a morbid sequela of necrotizing pancreatitis. Definitive surgical management can be accomplished by either fistulojejunostomy (FJ) or distal pancreatectomy (DP). It is unclear which operative approach is superior with regard to short- and long-term outcomes.

METHODS

Between 2002 and 2014, patients undergoing either FJ or DP for DDP were retrospectively identified at a center specializing in pancreatic diseases. Patient demographics, perioperative, and postoperative variables were evaluated.

RESULTS

Forty-two patients with DDP secondary to necrotizing pancreatitis underwent either a FJ (n = 21) or DP (n = 21). Between the two cohorts, there were no significant differences in overall lengths of stay, pancreatic leak rates, or readmission rates (all p > 0.05). DP was associated with higher estimated blood loss, increased transfusion requirements, and worsening endocrine function (all p < 0.05). At a median follow-up of 18 months, four patients that underwent a FJ developed a recurrent fluid collection requiring re-intervention. Overall, FJ was successful in 80% of patients as compared to a 95% success rate for DP (p = 0.15).

CONCLUSIONS

Although DP was associated with higher intraoperative blood loss, increased transfusion requirements, and worsening of preoperative diabetes, this procedure provides superior long-term resolution of a DDP when compared to FJ.

Salvage anastomosis for postoperative chronic pancreatic fistula

Salvage anastomosis for postoperative chronic pancreatic fistula is challenging, and its safety and surgical outcomes remain unclear. Four patients with postoperative chronic pancreatic fistulas who underwent surgical interventions in our institute were retrospectively reviewed. A re-pancreatojejunostomy was performed in two patients with a disruption of the pancreatojejunostomy and a dilated main pancreatic duct of the remnant pancreas. A fistulojejunostomy was performed in the remaining two patients with a duct disruption after necrosectomy for necrotic severe acute pancreatitis and non-dilated main pancreatic duct. The median duration from the onset of the pancreatic fistula to the surgical intervention was 4.5 months (range 4-6 months). The median operation time was 151 min (range 38-257 min) and the median blood loss was 200 mL (range 5-350 mL). According to the Clavien-Dindo classification, one patient had grade 0, two patients had grade I, and one patient had grade II (wound infections). The median length of hospital stay was 22 days (range 21-28 days). There were no recurrences of pancreatic fistulas. Salvage anastomosis according to the simple radiologic classification for postoperative chronic pancreatic fistulas is a safe and effective procedure.

Early dual drainage combining transpapillary endotherapy and percutaneous catheter drainage in patients with pancreatic fistula associated with severe acute pancreatitis

BACKGROUND

The development of pancreatic fistula (PF) associated with pancreatic necrosis is of great concern in the management of severe acute pancreatitis (SAP). We expected that early recognition and intervention of PF combined with percutaneous catheter drainage (PCD) for pancreatic infection may improve SAP outcomes.

METHODS

Fifteen consecutive patients with SAP were enrolled. Whenever feasible, fine-needle aspiration for fluid collection was performed to determine infection and amylase concentration. For infection and PF with amylase-rich fluid, PCD and transpapillary endotherapy (preferably naso-pancreatic drainage) were carried out as soon as possible. PCD was intensively managed by irrigating the sized-up and multiple large bore catheters.

RESULTS

Infected fluid collection and PF were both detected in 13 (86.7%) patients. Pancreatic duct (PD) disruption (n = 6) and organ failure (n = 5) occurred exclusively in patients with amylase-rich collection ≥10,000 U/L. The median timing of PCD and endotherapy was 15.5 and 16.5 days, respectively. No serious complications or mortality resulted from intervention procedures other than stent occlusion in one (6.7%) patient. Surgical intervention due to uncontrollable infection and visceral organ injury was avoided. Fistula closure was achieved in 12 (92.3%) of 13 PF patients with a median duration of 45 days. Disease-related mortality occurred in one (6.7%) patient.

CONCLUSION

Amylase-rich fluid collection ≥10,000 U/L may be an indication for further endoscopic investigation of PD disruption. Early dual drainage combining pancreatic endotherapy and PCD is feasible and safe, and may improve treatment outcome.

Management of pancreatic ductal leaks and fistulae

Pancreatic duct leaks can occur as a result of both acute and chronic pancreatitis or in the setting of pancreatic trauma. Manifestations of leaks include pseudocysts, pancreatic ascites, high amylase pleural effusions, disconnected duct syndrome, and internal and external pancreatic fistulas. Patient presentations are highly variable and range from asymptomatic pancreatic cysts to patients with severe abdominal pain and sepsis from infected fluid collections. The diagnosis can often be made by high-quality cross-sectional imaging or during endoscopic retrograde cholangiopancreatography (ERCP). Because of their complexity, pancreatic leak patients are best managed by a multidisciplinary team comprised of therapeutic endoscopists, interventional radiologists, and surgeons in the field of pancreatic interventions. Minor leaks will often resolve with conservative management while severe leaks will frequently require interventions. Endoscopic treatments for pancreatic duct leaks have replaced surgical interventions in many situations. Interventional radiologists also have the ability to offer therapeutic interventions for many leak patients. The mainstay of endotherapy for pancreatic leaks is transpapillary pancreatic duct stenting with a stent that bridges the leak if possible, but varies based on the manifestation and clinical presentation. Fluid collections that result from leaks, such as pseudocysts, can often be treated by endoscopic transluminal drainage with or without endoscopic ultrasound or by percutaneous drainage. Endoscopic interventions have been shown to be effective and have an acceptable complication rate.

Alcoholic severe acute pancreatitis with positive culture of pancreatic juice treated by nasopancreatic drainage

BACKGROUND

Severe acute pancreatitis (SAP) is a serious disease associated with alcoholism and has a high mortality rate. Effective treatments have not been established.

METHODS

A 58-year-old man was admitted due to alcoholic SAP. Endoscopic retrograde cholangiopancreatography revealed pancreatic calculi at the pancreas head and a stricture in the pancreatic duct from the pancreas head to the body. Endoscopically, nasopancreatic drainage (NPD) was placed through the minor papilla to the pancreas tail beyond the stricture.

RESULTS

Pancreatic juice culture was positive for Streptococcus and Enterobacter. The day after NPD, upper abdominal pain was relieved. After changing NPD to a pancreatic stent, the patient was discharged on day 21 post-NPD.

CONCLUSION

Alcoholic SAP may reflect aggravation of chronic pancreatitis. The possibility of acute bacterial inflammation should be considered in all cases of chronic alcoholic pancreatitis who present with severe features of inflammation, even in the early stages of an attack. Treatment of this subset of cases by drainage could be of great importance and NPD may be the preferred method.

Endoscopic therapy for pancreatic duct leaks and disruptions

Pancreatitis, whether acute or chronic, can lead to a plethora of complications, such as fluid collections, pseudocysts, fistulas, and necrosis, all of which are secondary to leakage of secretions from the pancreatic ductal system. Partial and side branch duct disruptions can be managed successfully by transpapillary pancreatic duct stent placement, whereas patients with disconnected pancreatic duct syndrome require more complex endoscopic interventions or multidisciplinary care for optimal treatment outcomes. This review discusses the current status of endoscopic management of pancreatic duct leaks and emerging concepts for the treatment of disconnected pancreatic duct syndrome.

Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video)

BACKGROUND

An external pancreatic fistula (EPF) generally results from an iatrogenic manipulation of a pancreatic fluid collection (PFC), such as walled-off pancreatic necrosis (WOPN). Severe necrotizing pancreatitis can lead to complete duct disruption, causing disconnected pancreatic duct syndrome (DPDS) with viable upstream pancreas draining out of a low-pressure fistula created surgically or by a percutaneous catheter. The EPF can persist for months to years, and distal pancreatectomy, often the only permanent solution, carries a high morbidity and defined mortality.

OBJECTIVE

To describe 3 endoscopic and percutaneous rendezvous techniques to completely resolve EPFs in the setting of DPDS.

DESIGN

A retrospective review of a prospective database of 15 patients who underwent rendezvous internalization of EPFs.

SETTING

Tertiary-care pancreatic referral center.

PATIENTS

Fifteen patients between October 2002 and October 2011 with EPFs in the setting of DPDS and resolved WOPN.

INTERVENTION

Three rendezvous techniques that combined endoscopic and percutaneous procedures to internalize EPFs by transgastric, transduodenal, or transpapillary methods.

MAIN OUTCOME MEASUREMENTS

EPF resolution and morbidity.

RESULTS

Fifteen patients (12 men) with a median age of 51 years (range 24-65 years) with EPFs and DPDS (cutoff/blowout of pancreatic duct, with inability to demonstrate upstream body/tail of pancreas on pancreatogram) resulting from severe necrotizing pancreatitis underwent 1 of 3 rendezvous procedures to eliminate the EPFs. All patients were either poor surgical candidates or refused surgery. At the time of the rendezvous procedure, WOPN had fully resolved, DPDS was confirmed on pancreatography, and the EPF had persisted for a median of 5 months (range 1-48 months), producing a median output of 200 mL/day (range 50-700 mL/day). The rendezvous technique in 10 patients used the existing percutaneous drainage fistula to puncture into the stomach/duodenum to deliver wires that were captured endoscopically. The transenteric fistula was dilated and two endoprostheses placed into the lesser sac. A second technique was used in 3 patients where EUS was used to avoid large varices and create a fistula to the percutaneous drainage catheter. Wires were delivered transenterally then grasped by an interventional radiologist. The new fistula was dilated, and, again, two endoprostheses were placed. Two patients underwent a rendezvous technique that resulted in transpapillary stents and removal of percutaneous catheters. The median duration to EPF closure was 7 days (range 1-73 days) during a median follow-up of 25 months (range 6-113 months). No EPF has recurred in any patient, although 3 symptomatic fluid collections have occurred. These collections have been successfully treated with combined percutaneous and endoscopic treatment or endoscopic treatment alone. One patient had postprocedural fever. There were no associated deaths.

LIMITATIONS

Small, selected group of patients without a comparative group.

CONCLUSION

The management of EPFs in the setting of DPDS is challenging but can be treated effectively by combined endoscopic and percutaneous rendezvous techniques. The rendezvous procedures were associated with minimal morbidity, no mortality, avoidance of surgery, and complete elimination of the EPFs.

After distal pancreatectomy pancreatic leakage from the stump of the pancreas may be due to drain failure or pancreatic ductal back pressure

HYPOTHESIS

The method to lower postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) involves controlling risk factors for leakage from the pancreatic stump.

GOAL

The aim of this study was to identify controllable risk factors for POPF.

METHODS

In order to promote homogeneity, we used a single surgeon case series and then calculated POPF with a public web-based tool based on the severity classification system of the International Study Group of Pancreatic Surgery (ISGPS). A total of 223 consecutive cases of DPs were reviewed. DP involved the same hand-sewn fish-mouth closure of the pancreatic stump. All received postoperative epidural anesthesia. Logistic regression analysis identified risk factors for clinically relevant POPF (grade B/C).

RESULTS

Mortality was zero. ISGPS gradings were: no POPF 53%, grade A = 32%, B = 13.9%, and C = 0.9%. The clinical-relevant POPF (B/C) rate was 14.8% of which 24% represented surgical drain failure due to lack of patency and/or misplaced from their original location. Preoperative endoscopic ablation and/or stenting of Wirsung's duct was a significant risk factor to lower grade B/C leak (3%). Multivariate analysis identified two controllable risk factors-intraoperative blood loss >1,000 ml and those who did not undergo preoperative endoscopic interventions of Wirsung's duct. In the group with presumed intact pancreatic sphincters (no endoscopic intervention, n = 177), the use of postoperative intravenous opioids (with epidural failure) was a risk factor for B/C leak (34%). These findings suggest that increased back pressure in the pancreatic duct has a role in promoting pancreatic stump leakage.

CONCLUSIONS

Using the ISGPS definition and its web-based tool, the incidence of clinically relevant leakage was 14.8% in 223 cases of DP. Opportunities to lower this rate are improving our surgical drain technology, limiting intraoperative blood loss, and avoiding postoperative intravenous narcotics with epidural analgesia.

Systematic review and meta-analysis of somatostatin analogues for the treatment of pancreatic fistula

BACKGROUND

Somatostatin analogues are used for the treatment of pancreatic fistula, with the aim of achieving fistula closure or reduction of output.

METHOD

MEDLINE, Embase and Cochrane databases were searched systematically for relevant articles followed by hand-searching of reference lists. Data on patient recruitment, intervention and outcome were extracted and meta-analysis performed where reasonable.

RESULTS

Seven randomized clinical trials met the inclusion criteria and included a total of 297 patients with fistulas of the gastrointestinal tract; of these, 102 patients had fistulas of pancreatic origin. Pooling of closure rates showed no significant difference between patients treated with somatostatin analogues compared with controls: odds ratio 1·52 (95 per cent confidence interval 0·88 to 2·61). Owing to inconsistent descriptions, pooling of results was not possible for other endpoints, such as time to fistula closure.

CONCLUSION

There is no solid evidence that somatostatin analogues result in a higher closure rate of pancreatic fistula compared with other treatments.

Endoscopic naso-pancreatic drainage for the treatment of pancreatic fistula occurring after LDLT

Pancreatic fistula is a quite rare complication in patients who undergo living donor liver transplantation (LDLT). However, in the cases that show pancreatic fistula, the limited volume of the graft and the resultant inadequate liver function may complicate the management of the fistula. As a result, the pancreatic fistula may result in the death of the patient. We present 2 cases in which endoscopic treatment was effective against pancreatic fistulas that developed after LDLT. In case 1, a 61-year-old woman underwent LDLT for primary biliary cirrhosis. Because of a portal venous thrombus caused by a splenorenal shunt, the patient underwent portal vein reconstruction, and a splenorenal shunt was ligated on postoperative day (POD) 7. The main pancreatic duct was injured during the manipulation to achieve hemostasis, thereby necessitating open drainage. However, discharge of pancreatic fluid continued even after POD 300. Endoscopic naso-pancreatic drainage (ENPD) was performed, and this procedure resulted in a remarkable decrease in drain output. The refractory pancreatic fistula healed on day 40 after ENPD. In case 2, a 58-year-old man underwent LDLT for cirrhosis caused by the hepatitis C virus. When the portal vein was exposed during thrombectomy, the pancreatic head was injured, which led to the formation of a pancreatic fistula. Conservative therapy was ineffective; therefore, ENPD was performed. The pancreatic fistula healed on day 38 after ENPD. The findings in these 2 cases show that endoscopic drainage of the main pancreatic duct is a less invasive and effective treatment for pancreatic fistulas that develop after LDLT.

Chronic pancreatitis: modern surgical management

INTRODUCTION

Chronic pancreatitis (CP) is a disease with enormous social and personal impact. It is most commonly caused by the abuse of alcohol combined with nicotine. CP is usually characterised by an inflammatory mass located in the pancreatic head. Its natural course is characterised by persistent or recurrent painful attacks as well as progressive loss of pancreatic function due to fibrosis of the parenchyma with consecutive endocrine and exocrine insufficiency.

CONCLUSIONS

The only success parameter of any treatment is the effective long-lasting pain relief and improvement in the quality of life. The surgical armamentarium includes simple drainage procedures, resections of different extents or a combination of both. Duodenum-preserving resection of the pancreas offers the best short-term outcome according to trials conducted so far. It has the benefit of combining the highest safety with the highest efficiency. Additionally, the extent of the operation can be adapted to the morphology of the individual patient.

Endoscopic transpapillary drainage for external fistulas developing after surgical or radiological pancreatic interventions

BACKGROUND AND AIMS

External pancreatic fistulas (EPFs) are a therapeutic challenge. The present study was conducted to evaluate the efficacy of endoscopic transpapillary nasopancreatic drainage (NPD) in patients with EPF.

METHODS

Over 12 years, 23 patients (19 males) with EPF underwent attempted endoscopic transpapillary NPD. The end points were fistula closure with healing of pancreatic duct disruption on nasopancreatogram, or need for surgery.

RESULTS

All 23 patients had persistent drain output (>50 mL/day) for >6 weeks. The mean output volume of the fistula was 223 mL (range: 60 mL to 750 mL). Sixteen patients had partial and seven patients had complete pancreatic duct disruption. The NPD could be successfully placed in 21/23 (91.3%) patients. Disruption was bridged in 15 of 16 patients with partial duct disruption. EPF healed in 2-8 weeks of placement of NPD in all of the patients with partial duct disruption that was bridged and there was no recurrence at a mean follow-up of 38 months. The EPF resolved in only 2/6 (33%) patients with complete duct disruption.

CONCLUSIONS

External pancreatic fistulas developing following percutaneous drainage of pancreatic fluid collections or surgical necrosectomy can be effectively treated by transpapillary nasopancreatic drain placement especially when there is partial ductal disruption and the disruption can be bridged.

Quality improvement for pancreatic cancer care: is regionalization a feasible and effective mechanism?

Variability exists in the quality of pancreatic cancer care provided in the United States. High-volume centers have been shown to have improved outcomes for pancreatectomy. Regionalization of pancreatic cancer care to high-volume centers has the potential to improve care and outcomes. Practical limitations such as overloading currently available high-volume centers, extending patient travel times, sharing patients within a multipayer health system, and incorporating patient preferences must be addressed for regionalization to become a reality. The benefits and limitations of regionalization of pancreatic cancer care are discussed in this review. To improve the overall quality of pancreatic cancer care at all hospitals in the United States, a combination of referral of patients with pancreatic cancer to high- and moderate-volume hospitals in conjunction with specific quality-improvement efforts at those institutions is proposed.

Local pancreatic resection with preoperative endoscopic transpapillary stenting

BACKGROUND

Pancreatic fistula, although not common, can cause serious complications after pancreatectomy. During local pancreatectomy, injury to the main pancreatic duct (in addition to the accessory and side branch ducts) increases the risk of pancreatic fistula formation. Nonetheless, local pancreatic resection maintains the advantage of preserving pancreatic parenchyma.

METHODS

In this study, we reviewed the cases of 5 patients who underwent preoperative endoscopic transpapillary pancreatic stenting to help prevent refractory fistula development after local pancreatic resection.

RESULTS

Stenting was successful in all 5 patients, and none developed a refractory grade C postoperative pancreatic fistula.

CONCLUSIONS

These results suggest that in selected patients, preoperative endoscopic pancreatic stenting may be an effective prophylactic measure to lower the risk of refractory grade C fistula formation after local pancreatic resection.

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.

Endoscopic treatment of external pancreatic fistulas: when draining the main pancreatic duct is not enough

OBJECTIVES

Transpapillary drainage of the main pancreatic duct (MPD) has been proposed for the treatment of external pancreatic fistulas (EPF) but may not suffice to treat complex cases. The aim of the present study was to explore the efficacy of various endoscopic or combined percutaneous and endoscopic techniques in the treatment of EPFs.

METHODS

Sixteen patients presenting with EPFs were treated in our department. The techniques applied and patients' clinical outcome are described.

RESULTS

All but three patients underwent transpapillary MPD drainage by pancreatic sphincterotomy (N = 13). Additional endoscopic procedures performed were: (a) pancreatic fluid collection (PFC) drainage (N = 5), (b) transmural drainage between the fistula path and the gastrointestinal (GI) tract (N = 5), and (c) endoscopic ultrasound (EUS)-guided pancreaticoduodenostomy because of complete pancreatic duct rupture (N = 1). Fistula closure was achieved in all patients except one, who required surgery. During a median follow-up period of 18 months (range 6-52) three patients had fistula recurrence, and two, PFC recurrence. Both conditions were cured successfully by repeated endoscopic therapy. All recurrences occurred within 3 months of initial successful treatment.

CONCLUSIONS

Combined endoscopic and percutaneous treatment appears to be safe and effective for the management of complex cases of EPFs.

Fistule pancréatique post-traumatique : succès du traitement endoscopique par endoprothèse

INTRODUCTION

The risk of complications and the severity of pancreatic trauma depend on the status of the main pancreatic duct. Endoscopic retrograde pancreatography (ERCP) has emerged as the technique of reference for assessing pancreatic ductal anatomy, and it also permits therapeutic intervention by the endoscopic placement of an endoprosthesis.

CASE

We report a pancreatic fistula attributable to posttraumatic rupture of the main duct, undiagnosed before ERCP and successfully treated by endoscopic stent placement.

DISCUSSION

ERCP has emerged as a tool for both diagnosis and treatment. Major traumatic pancreatic duct disruptions can be diagnosed more easily and managed successfully by endoscopic stent placement, thereby avoiding surgical morbidity. ERCP is impractical in emergency settings for many reasons. Magnetic resonance pancreatography may be useful for establishing the type and extent of pancreatic lesions and for selecting patients for endoscopic treatment.

Endoscopic treatment of pancreatic fistulas

BACKGROUND

Pancreatic fistulas are managed primarily by conservative treatment. Surgery is performed in cases of conservative treatment failure. Endoscopic treatment is reported to be both effective and safe as an alternative treatment method.

METHODS

A total of 26 patients underwent endoscopic treatment after failure of conservative treatment between January 2002 and November 2004. The mean time between the onset of fistula and the endoscopic retrograde cholangiopancreatography (ERCP) procedure was 95 days. The mean fistula output volume was 400 ml per day. Four patients had pancreatic ascites. The aim of the endoscopic treatment was to bypass the ductal disruption by placing stents or drains where the origin of fistulous tract could be identified, and to lower the pancreatic duct pressure by performing pancreatic sphincterotomy or by placing stents where the site of the leak could not be identified.

RESULTS

Pancreatography could be performed in all the patients except one. Partial duct disruption occurred in 16 patients. All of the fistulas closed after the ductal disruption was bypassed. Pancreatic sphincterotomy or endoprothesis placement was effective for eight of the remaining nine patients in whom the ductal disruption originated from the tail of the pancreas and hence could not be bypassed. The overall success rate was 94% for the patients with partial duct disruption. Four patients had side branch leaks. All of them closed after placement of an endoprothesis. Fistulas closed in only one (20%) of the five patients with complete duct disruption. Pancreatic ascites resolved in two of the four patients after endoscopic treatment. No serious complications resulted from endoscopic treatment other than proximally migrated stents in two patients.

CONCLUSIONS

Endoscopic treatment is an effective and safe method for patients with pancreatic fistulas unresponsive to conservative treatment. The success rate is very high, especially for patients with partial and side branch duct disruption.

Diagnosis of duct disruption and assessment of pancreatic leak with dynamic secretin-stimulated MR cholangiopancreatography

OBJECTIVE

The management of pancreatic duct disruption is complex and depends on several factors including the cause, morphology, and degree of disruption. ERCP can show duct disruption in as many as 75% of patients but is invasive and cannot detect disruption beyond an obstruction. We studied the role of secretin MR cholangiopancreatography in patients with suspected pancreatic duct disruption.

CONCLUSION

Secretin MR cholangiopancreatography is a safe, noninvasive test that can provide additional useful information about duct integrity and facilitate management.

Endoscopic management of pancreatic fistula after pancreatic and other abdominal surgery

Post-operative pancreatic fistulae represent a challenge for all the actors in gastroenterology: for surgeons, because they want to prevent and treat conservatively this complication since re-operation is associated with high morbidity and mortality rates; for radiologists, because they have to provide the best staging and informations without any additional risk; and for endoscopists, because endoluminal treatment is emerging as a safe and effective procedure provided it is performed in highly experienced tertiary centres in the setting of a multidisciplinary approach. Herein, we review the definitions, the causes, the staging and the possible options to prevent or treat post-operative pancreatic fistulae. Special attention is paid to the endoscopic management of this complication: including the relief of ductal obstructions, the stenting of leakages and the drainage of bulging or non-bulging fluid collections. Practical problems and issues are clearly outlined as well as the need for future improvements in staging and management of the patients having such complications.

Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients

PURPOSE

The lack of ductal continuity between a viable pancreatic tissue and the gastrointestinal tract results in the disconnected pancreatic duct syndrome (DPDS). The purpose of our study is to describe accurately the imaging features of CT scanning and endoscopic retrograde pancreatography (ERCP) that define the DPDS.

METHODS

We conducted a retrospective analysis of the computed tomography (CT) and ERCP examinations in 26 consecutive patients with surgically proven disconnected pancreatic ducts treated over a 5-year period at our institution. Two abdominal radiologists concurrently defined the imaging features (presence and size of fluid collection along the course of the pancreatic duct, upstream enhancing pancreatic parenchyma, and ERCP abnormalities) via consensus for both exams. Patient demographics, etiology of pancreatitis, surgical treatment, initial CT interpretation, and the delay between symptom onset to correct diagnosis were recorded.

RESULTS

A discrete, intrapancreatic fluid collection (average size = 27 cm2 (range, 4-74 cm2) along the course of the main pancreatic duct with upstream viable pancreatic parenchyma was identified by CT in 26 cases. ERCP showed ductal obstruction at the level of the intrapancreatic fluid collection in all patients with extravasation of contrast in 14 (54%). All patients were treated by operation: 15 (58%) by internal drainage into a Roux-en-Y limb of jejunum and 11 (42%) by distal pancreatic resection. No prior CT interpretation correctly identified DPDS. The average delay between symptom onset and definitive diagnosis was 9.3 months (range, 3-36 months).

CONCLUSIONS

A discrete intrapancreatic fluid collection along the expected course of the main pancreatic duct with viable upstream pancreatic parenchyma suggests the diagnosis of DPDS. ERCP findings of ductal obstruction at the level of this fluid collection with or without contrast extravasation confirm this diagnosis. Treatment is surgical and requires either internal drainage or distal pancreatic resection for complete resolution.

Roux-en-Y internal drainage is the best surgical option to treat patients with disconnected duct syndrome after severe acute pancreatitis

BACKGROUND

Roux-en-Y (RNY) internal drainage has been our primary surgical strategy to definitively treat disconnected duct syndrome in patients after severe acute pancreatitis (SAP). This study compares the results of internal drainage with the results of distal pancreatectomy-splenectomy (DPS) performed in a contemporaneous group of patients.

METHODS

For 5 years (June 1995 to June 2000), 27 consecutive patients with disconnected duct syndrome after SAP were identified: 13 treated with internal drainage and 14 with DPS. Fistula characteristics, operative management, and clinical outcome were analyzed. Comparisons between groups were made with the Student t test and Fisher exact test, with statistical significance defined as P <.05.

RESULTS

Age, sex, etiology of pancreatitis, comorbid diseases, and prior operations were similar between groups. Internal drainage required less operative time (211 +/- 37 vs 269 +/- 88 minutes, P =.04), blood loss (735 +/- 706 vs 2757 +/- 3062 mL, P =.03), and transfusion requirements (0.69 +/- 1.7 vs 4.21 +/- 8.0 units, P =.05). Clinical outcomes--as measured by postoperative complication rate, reoperation rate, fistula recurrence rate, and death rate--were similar between groups.

CONCLUSIONS

RNY internal drainage, when technically feasible, is the best surgical option to treat disconnected duct syndrome after SAP.

Interventional endoscopic retrograde cholangiopancreatography and endoscopic surgery

Interventional endoscopic techniques have been indespensible in almost every area of modern surgery. As surgeons, we need to continue to advance our skills in these areas if we expect to continue to be involved in these aspects of patient care.

Persistent pancreatocutaneous fistula after percutaneous drainage of pancreatic fluid collections: role of cause and severity of pancreatitis

PURPOSE

To assess the relationship between the cause and severity of pancreatitis and the development of persistent pancreatocutaneous fistula (PPCF) after percutaneous drainage of pancreatic fluid collections.

MATERIALS AND METHODS

Sixty patients (44 male, 16 female; age range, 10-74 years) were included in the study. The cause of pancreatitis was postoperative in 29 patients, alcoholism in 20 patients, biliary in six patients, hyperlipidemia in two patients, unknown in two patients, and trauma in one patient. Patients requiring intensive care unit treatment for their condition at the time of drainage were considered to have severe pancreatitis. Thirty-seven patients had mild pancreatitis, and 23 had severe pancreatitis. PPCF was defined as catheter drainage of pancreatic fluid of more than 10 mL/d for more than 4 weeks after catheter placement.

RESULTS

PPCF developed in 27 of the 60 patients. It occurred in five of the six patients with biliary pancreatitis, 10 of the 20 with alcohol-related pancreatitis, and 10 of the 29 with postoperative pancreatitis (P > .2). The prevalence of PPCF was higher in patients with severe pancreatitis (n = 16 [70%]) than in those with mild pancreatitis (n = 11 [30%]). This difference was statistically significant (P < .002).

CONCLUSION

Development of PPCF correlated with severity of pancreatitis, regardless of the cause of pancreatitis.

Contemporary treatment strategies for external pancreatic fistulas

BACKGROUND

Optimal treatment strategies for patients with external pancreatic fistulas have evolved with improved radiographic imaging and the development of transpapillary pancreatic duct stents. The aim of this study was to examine factors affecting fistula closure and develop a classification scheme to guide therapeutic interventions.

METHODS

Retrospective chart review was made of all patients with external pancreatic fistulas treated at our institution from January 1991 to January 1997. Side (partial) fistulas maintained continuity with the gastrointestinal tract; end (complete) fistulas had no continuity with the gastrointestinal tract.

RESULTS

Postoperative side fistulas resolved with medical treatment in 13 (86%) of 15 patients after a mean of 11 weeks of conservative management. Inflammatory side fistulas resolved with medical treatment in only 8 (53%) of 15 patients after a mean of 22 weeks; those that did not close initially did so with transpapillary stenting. End pancreatic fistulas never closed with medical treatment and were unable to be stented; therefore internal drainage or pancreatic resection was necessary to achieve closure. There were no differences in sepsis rates, Acute Physiology and Chronic Health Evaluation II scores, fistula site, total parenteral nutrition, somatostatin treatment, or initial fistula output between groups.

CONCLUSIONS

Classifying external pancreatic fistulas as to their pancreatic duct relationship and cause provides important prognostic and therapeutic information.