Document Detail

Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video).
MedLine Citation:
PMID:  22898416     Owner:  NLM     Status:  In-Data-Review    
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.
Shayan Irani; Michael Gluck; Andrew Ross; S Ian Gan; Robert Crane; John J Brandabur; Ellen Hauptmann; Mehran Fotoohi; Richard A Kozarek
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Gastrointestinal endoscopy     Volume:  76     ISSN:  1097-6779     ISO Abbreviation:  Gastrointest. Endosc.     Publication Date:  2012 Sep 
Date Detail:
Created Date:  2012-08-17     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0010505     Medline TA:  Gastrointest Endosc     Country:  United States    
Other Details:
Languages:  eng     Pagination:  586-593.e3     Citation Subset:  IM    
Copyright Information:
Copyright © 2012. Published by Mosby, Inc.
Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA.
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