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Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video)
ORIGINAL ARTICLE: Clinical Endoscopy
Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video) Shayan Irani, MD,1 Michael Gluck, MD,1 Andrew Ross, MD,1 S. Ian Gan, MD,1 Robert Crane, MD,2 John J. Brandabur, MD,3 Ellen Hauptmann, MD,2 Mehran Fotoohi, MD,2 Richard A. Kozarek, MD1 Seattle, Washington, USA
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. (Gastrointest Endosc 2012;76:586-93.) (footnotes appear on last page of article)
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A pancreatic fistula can result from several causes, including pancreatic surgery,1-3 surgery near the pancreas,4,5 and as a consequence of severe pancreatitis.6 An external pancreatic fistula (EPF), also known as a pancreaticocutaneous fistula, is generally the result of an iatrogenic manipulation (percutaneous or operative) of a pancreatic fluid collection (PFC), especially walled-off pancreatic necrosis (WOPN). The 3 basic tenets of management of pancreatic fistulas are stabilization and medical optimization, understanding the anatomy of the ductal disruption, and the definitive management of the fistula (medical, endoscopic, or surgical). Medical management consisting of fasting, nutritional support, and octreotide usually is slow to work and rarely is effective by itself.7 Traditionally, after failed medical management, surgery was the next treatment option, but surgery is associated with a high morbidity and mortality.8 Endoscopic management of EPFs was developed as a less invasive approach but is dependent on an intact main pancreatic duct to allow resolution of the fistula by reducing the downstream pressure gradient across the papilla into the duodenum by means of transpapillary stenting.9-12 Acute necrotizing pancreatitis and WOPN often result in main pancreatic duct disruption, often leaving a fair amount of functional pancreas upstream of the complete disconnection (disconnected pancreatic duct syndrome [DPDS]).13 Transpapillary drainage alone is not adequate in such situations. Percutaneous or surgical drainage of WOPN in this setting provides a low-pressure system to the outside that resolves the fluid collection. Unfortunately, these drains perpetuate the flow of pancreatic juice externally, occasionally resulting in a high-output EPFs that can drain upward of 400 mL/day.14 Multiple case series in which patients were treated with external drainage of WOPN note a rate of DPDS approaching 50%, resulting in high EPF rates.15,16 Patients with persistent EPFs are left with the option of a long-term percutaneous drain (a major inconvenience and predisposing factor for infection) or surgery (distal pancreatectomy) that is associated with significant morbidity and mortality in this setting because of adhesions, splenic vein thrombosis, and varices.8 In prior case series,17-19 our team has described a combined endoscopic and percutaneous drainage of symptomatic WOPN called dual modality drainage. By placing transgastric or transduodenal stents into WOPN at the time of percutaneous drainage, we were able to avoid the development of EPFs in all patients by diverting the pancreatic juice from the disconnected gland enterally. There have been prior case series describing the management of DPDS with existing PFCs,20,21 where transmural drainage of the PFCs alone was able to provide drainage for the disconnected pancreatic gland. However, in the absence of a PFC to target for endoscopic drainage, management of a fistula without a fluid collection can be even more challenging. With the prinwww.giejournal.org
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Take-home Message ●
The authors describe the successful use of 3 endoscopic and percutaneous rendezvous techniques to resolve external pancreatic fistulas associated with a disconnected pancreatic duct syndrome, precluding a difficult operation in all patients, with minimal morbidity and no mortality.
cipal goal in mind of diverting pancreatic juice enterally, we developed an approach to treat persistent EPFs in patients with DPDS after complete resolution of all PFCs by using a combined endoscopic and percutaneous rendezvous approach to avoid the need for surgery. We present our data on managing 15 such patients by using 3 different rendezvous techniques.
PATIENTS AND METHODS Patients From October 2002 to October 2011, 15 patients (12 men) with EPFs and DPDS resulting from WOPN were treated at our institution. Three patients were identified retrospectively from an internal review board–approved database, and the other 12 were included prospectively. All patients were followed after the procedures with clinic visits and imaging studies. This study was approved by the internal review board at our institution. The median age of the patients was 51 years (range 24-65 years). Patients developed persistent EPFs as a consequence of manipulation (surgical 4, percutaneous 11) of WOPN. The treated fluid collections had resolved completely, and attempts to remove the percutaneous drains had failed by using conservative measures. All patients had DPDS based on endoscopic retrograde pancreatography. There was viable pancreatic parenchyma in the body and/or tail of the pancreas based on cross-sectional imaging (CT and or MRCP) and persistent high levels of amylase fluid (⬎20,000 units/L) in the drainage catheters. Patients with fistula outputs of ⬍200 mL/day were given a chance for spontaneous fistula closure with total parenteral nutrition or jejunal elemental nutrition and/or a trial of octreotide. All patients were deemed poor surgical candidates or refused surgery (Table 1, available online at www.giejournal.org). Prior attempts at fistula drainage via EUS alone had failed in 2 patients because of the inability to obtain enough wire purchase in the fistulous tract to dilate through tract scarring (consequence of the healed WOPN) to allow for the placement of transgastric stents.
Definitions An EPF was defined as the presence of a tract leading from the pancreatic duct to the abdominal or chest wall. Volume 76, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 587
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Figure 1. Disconnected pancreatic duct syndrome. A, Complete cutoff of the pancreatic duct (large arrow). B, Blowout of the pancreatic duct (large arrow).
DPDS was defined as a cutoff (n ⫽ 13) or blowout (n ⫽ 2) of the pancreatic duct, with the inability to demonstrate upstream the body/tail of the pancreas on a pancreatogram (Fig. 1). The upstream disconnected body/tail of the pancreas was the source of the EPF in all cases and was identified at fistulogram or MRCP. Persistence of the EPF was determined by fistula output in excess of 50 mL/day, with amylase levels greater than 20,000 units/L and no residual WOPN on CT scanning. Successful closure of the EPF was defined by the ability to remove the percutaneous drain without any further pancreatic juice draining to the skin, and the time to closure was defined as the days required to achieve success. Number of procedures was defined by the quantity of rendezvous procedures performed to achieve success. A recurrent PFC was defined as formation of a fluid collection after removal of the percutaneous drains.
Technique After stabilization of the patient and optimal patient medical condition, interventional radiologists and therapeutic gastroenterologists conferred after jointly reviewing imaging study results (CT, MRCP, fistulogram, and endoscopic retrograde pancreatography) on each patient to determine the optimal route for transenteral fistula creation to divert the pancreatic juice enterally. Careful attention was paid to the size and location of varices potentially in the path of the internalization tract. Patients received antibiotics before the procedure and were allowed a lowfat diet as tolerated after the procedure. Outside-in interventional radiologist– guided transgastric/duodenal puncture (n ⴝ 10). This was the preferred technique and has been reported previously in 1 prior case series.14 The existing EPF in which the percutaneous catheter resided was assessed for proximity 588 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 3 : 2012
to the stomach/duodenum, and a path into the GI lumen that was free of any vasculature was determined. A stiff wire (Amplatz stiff wire; Cook Medical, Winston-Salem, NC) was advanced through the existing percutaneous tract to the site of pancreatic duct disruption and was manipulated to approximate the gastric/duodenal wall. A duodenoscope was used to insufflate the stomach/ duodenum. The radiologist then punctured the gastric/ duodenal wall (under fluoroscopic and endoscopic guidance) by using a transjugular intrahepatic portosystemic shunt needle (angled needle catheter combination; Cook Medical, Winston-Salem, NC). A flexible 0.035 Jagwire (Boston Scientific, Natick, Mass) was then delivered percutaneously through the needle, captured, and brought out of the endoscope. Over that working wire, the radiologist then delivered a 6.5F, Lieberman introducer (Cook Medical) through which a second wire was advanced, then similarly captured and brought out of the endoscope. With two wires secured at both ends (endoscopically by the gastroenterologist and percutaneously by the radiologist) the gastric/duodenal tract was balloon dilated to 8 or 10 mm under fluoroscopic guidance. Two double-pigtail stents were then delivered into the fistula tract adjacent to the pancreatic ductal disruption with the proximal portions deployed in the gastric/ duodenal lumen (Table 2, available online at www.giejournal.org). The radiologist then left a safety drain in the portion of the EPF between the ductal disruption and the skin, through which contrast material was injected to assure adequate diversion into the gastric/duodenal lumen. After that injection, the drainage catheter was capped to encourage flow into the stomach/duodenum (Fig. 2). Inside-out EUS-guided fistula puncture (n ⴝ 3). This technique was used in 2 patients with very large varices in the expected tract of the needle puncture by the www.giejournal.org
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Figure 2. Outside-in interventional radiology– guided transgastric puncture. A, Disconnected pancreatic tail outlined at fistulogram. B, Catheter over stiff wire advanced to gastric lumen. C, and D, Transjugular intrahepatic portosystemic shunt (TIPSS) needle used to puncture gastric wall. E, and F, Wire passed through TIPSS needle and pulled through the endoscope. G, and H, Two double-pigtail stents deployed in fistula. I, Finally, a fistulogram through a safety drain confirms diversion through stents to the gastric lumen.
radiologist and in 1 patient in whom the direction of the needle puncture led away from the gastric lumen, precluding the outside-in approach. A linear array echoendoscope with Doppler (Olympus America, Inc, Center Valley, Pa) was used to assess and avoid varices and to perform a transgastric puncture (19-gauge needle) of the fistula toward the percutaneous drain. A 0.035 Jagwire (Boston Scientific, Natick, MA) was advanced through the needle into the fistula tract. The radiologist exchanged the drain for a 5F catheter through which a wire basket was used to snare the Jagwire under fluoroscopic guidance and pull it through the existing EPF tract. Having secured the wire at www.giejournal.org
both ends (percutaneous through the EPF and transgastric through the echoendoscope), we repeated steps as described earlier with the radiologist advancing a second wire through the echoendoscope, balloon dilation of the fistula, and placement of two transgastric stents (Video 1, available online at www.giejournal.org). Reconnecting the disconnected duct: interventional radiologist– guided transpapillary access and internalization (n ⴝ 2). If the radiologist had been able to demonstrate an upstream (toward the tail) and downstream (toward the duodenum) pancreatic duct on prior fistulograms, the goal of the rendezvous procedure was Volume 76, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 589
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Figure 3. Reconnecting the disconnected ducts. Interventional radiology-guided transpapillary rendezvous. A, Unable to demonstrate upstream pancreatic duct in body/tail via transpapillary pancreatogram. B, Fistulogram able to demonstrate disconnected body/tail and downstream, pancreatic duct. C, A wire passed downstream through the papilla percutaneously. D, Wire grasped endoscopically and papillotome pulled into the fistulous tract. E, and F, Transpapillary completion pancreatogram followed by wire advancement to disconnected tail performed for the first time.
to bridge the disconnection and reconnect the disconnected ducts. In performing this technique, the radiologist passed a thin, flexible wire (0.025 Glidewire; Terumo Corp, Tokyo, Japan) in an antegrade fashion from the ductal disruption where the previously placed drainage catheter resided and managed to manipulate the wire through the papilla. The wire was captured by the endoscopist and brought out of the duodenoscope. Over that wire, a papillotome was negotiated through the end of the pancreatic duct into the fistulous tract, something that had failed in prior attempts at endoscopic retrograde pancreatography alone. A complete pancreatogram was achieved by transpapillary injection for the first time, and a transpapillary wire was advanced into the upstream tail of the pancreas through the papillotome, over which balloon dilation of the fistula (now a new stricture) was performed. One or two straight transpapillary pancreatic duct stents were deployed to reconnect the disconnected ducts (Fig. 3).
Follow-up Patients were admitted overnight for observation and were discharged home the following day with the percutaneous drain capped and instructions to flush the drain 590 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 3 : 2012
twice daily with 10 mL of sterile normal saline solution. Rarely, the external drains were left to gravity for a few days if initial output was high or if infection was suspected. A CT scan was obtained in 2 to 4 weeks. If no new PFCs developed, and the drainage catheters produced less than 20 mL/day, implying adequacy of the internalization process, the external drain was removed. Patients were followed in the gastroenterology clinic every 3 to 6 months for the first year and then every 6 to 12 months for symptom assessment and cross-sectional imaging (CT or MRCP). For patients who were managed with transpapillary stenting, endoscopic retrograde pancreatography was performed twice more on each patient, to exclude exchange and eventual removal of the pancreatic duct stents over the ensuing year.
RESULTS Fifteen patients (12 men), median age 51 years (range 24-65 years), with persistent EPFs (median 5 months, range 1-48 months) and DPDS, after complete resolution of all PFCs resulting from severe necrotizing pancreatitis underwent 1 of 3 rendezvous procedures to eliminate the www.giejournal.org
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EPFs. The median EPF output was 200 mL/day (range 50-700 mL/day). Choledocholithiasis was the etiology of the pancreatitis in one-third of the patients. The other causes included alcohol use (14%), post-ERCP or ampullectomy state (14%), hypertriglyceridemia (14%), and other causes (28%). Three of 15 (20%) patients had a history of chronic pancreatitis. Ductal disruption occurred at the genu in 8 patients (54%) and in the body of the pancreatic duct in 7 patients (46%). Only 3 patients (20%) had purulent-appearing drainage at the time of the rendezvous procedure, whereas the rest had clear, serous drainage; all were amylase rich (⬎20,000 units/L). Pancreatography was performed in all 15 patients, demonstrating a complete main pancreatic duct cutoff (n ⫽ 13) or blowout/leak without demonstration of the upstream pancreatic duct in the body/tail (n ⫽ 2). These 2 patients were managed with transpapillary rendezvous. The median number of procedures performed on each patient was 1, and the median procedure time was 65 minutes (range 40-100 minutes). Only 1 patient needed two procedures to achieve successful closure of the EPF. A second procedure was performed to optimally place the second transgastric stent and, parenthetically, the patient also had a demonstrated colon fistula to the pancreatic bed that rapidly closed with diversion of pancreatic juice to the stomach. The 2 patients treated with transpapillary rendezvous had 2 more ERCPs each after closure of the EPFs, prior to successful removal of the pancreatic duct stents over the ensuing year (Tables 2 and 3, available online at www.giejournal.org). Successful closure of the EPF was achieved in all 15 patients at a median time of 7 days (range 1-73 days). There was no recurrence of EPF in any of the 15 patients at a median follow-up period of 25 months (range 6-113 months). Adverse events were graded as mild, moderate, and severe22 and occurred in 4 of 15 patients (27%). There has been no mortality, to date. One patient developed postprocedural fever that resolved with 7 days of oral antibiotics, requiring 2 additional hospital days (mild adverse event). Five patients developed a new PFC, of which 2 were asymptomatic (observed on follow-up cross-sectional imaging). Four patients had spontaneous migration of one or both transmural stents, of which 3 developed a new symptomatic PFC. They presented with an infected pseudocyst (fever and abdominal pain) at 68, 31, and 11 months, respectively. In 1 of these patients, the pigtail portion of the stent had fragmented in the fistula, whereas the remainder of the stent had spontaneously migrated out. Two of the 3 patients with infected pseudocysts were treated, in addition to antibiotics, with new percutaneous drains and EUS cystgastrostomy (including removal of the stent fragments by the interventional radiologist), and 1 was managed with EUS cystgastrostomy alone (moderate adverse event). To re-establish drainage of the disconnected gland in the third patient, an EUS-guided endowww.giejournal.org
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scopic retrograde pancreatography was performed to place a pancreatic duct stent through the existing duodenal fistula (site of prior transduodenal stents) into the dorsal pancreatic duct. The patient repeatedly declined surgery and hence was managed with two subsequent stent changes over the next year, with no PFC recurrences (stent-free follow-up at 14 months). The 2 asymptomatic patients, who developed small PFCs, had both their transmural stents intact.
DISCUSSION One of the most common causes of EPF is iatrogenic manipulation of symptomatic WOPN. The management of the latter has evolved from open surgical debridement23,24 to using less invasive techniques with substantially lower morbidity and mortality rates,25 such as percutaneous drainage by radiologists,26-28 minimally invasive surgery to include laparoscopic or video-assisted retroperitoneal dissection,29-31 direct endoscopic necrosectomy,32-34 and dual modality drainage,17-19 which combines endoscopic placement of transenteral stents with percutaneous drainage catheters. However, any management of WOPN that does not involve a transenteric route (transgastric necrosectomy and dual modality drainage) is associated with a significant risk for EPFs that persists as long as the upstream disconnected pancreas (DPDS) continues to drain into a lower pressure system through the percutaneous drain out to the skin. The persistent EPFs aggravate patients’ conditions, can persist for months to years, and could occlude required expedient exchanges to avoid serious infections. Definitive surgery (distal pancreatectomy) has a significant morbidity and defined mortality.8 Interventional radiologists have attempted EPF closure by injecting tissue adhesives such as fibrin glue and cyanoacrylate.35-38 Limitations of this technique include the need for recurrent injections, acute pancreatitis associated with cyanoacrylate, infections, and failures that have been attributed to ongoing active inflammation and pancreatitis. In addition, this method does not provide a drainage solution for the functional, disconnected pancreatic gland, which can result in the recurrence of the EPF or the formation of a new PFC.35,38 As an alternative to surgery or attempt at fistula closure by interventional radiology, a rendezvous endoscopic and percutaneous approach can be used to direct pancreatic secretions back into the intestinal lumen via transenteral stents, thus allowing for closure of the EPF by providing a new path of lower resistance for pancreatic juice. This allows closure of the EPF, prevents its recurrence or the development of a new PFC, and potentially preserves parenchymal function of the disconnected gland. To the best of our knowledge, there is only one prior case series14 describing 16 patients with persistent EPFs of various causes, including postoperative causes, who benefited by internalization of the pancreatic fistula done by use of an Volume 76, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 591
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endoscopic means alone or a rendezvous approach. This series, however, included 7 patients with PFCs larger than 3 cm that were treated endoscopically alone and 6 patients with leakage of a branch duct or partial main duct. Only 5 patients had no PFCs and a complete DPDS, similar to all 15 in our group (what we consider the most difficult group to treat), who were treated by a rendezvous technique. The first patient treated in the current study was in 2002, and dual modality drainage was introduced in 2007. Since 2007, we have performed dual modality drainage in over 70 patients without a single case of EPF despite a 50% incidence of DPDS. Unfortunately, some patients with WOPN do not have safe endoscopic routes for the placement of transenteral stents because of the lack of proximity to the stomach/duodenum, a need for early drainage due to early uncontrolled infections, or rarely, because of intervening varices. For these patients as well as those who had percutaneous drains placed at institutions that do not place transenteral endoprostheses, we have used the 3 rendezvous techniques described earlier to successfully resolve all EPFs without any recurrence at a median follow-up of 25 months. The described rendezvous techniques are not free of adverse events. Four of 15 patients (27%) had mild to moderate adverse events, 3 of whom required another intervention. However, there has been no mortality to date. The development of a new PFC was related to the loss of one or both transmural stents. This suggests that a single stent often will be inadequate to provide long-term drainage because of stent occlusion, and, thus, two stents provide drainage by allowing “wicking” between the prostheses. Pancreaticogastric fistulae will close in the absence of a simple patent prosthesis to maintain patency to the disconnected pancreatic gland. This has been demonstrated in prior studies, including a randomized trial from Europe that compared temporary and permanent stents for transmural drainage of PFCs. This study found that stent removal was associated with higher rates of PFC recurrence.39 Two of the concerns of permanent indwelling transmural prostheses are that stent occlusion or migration could lead to PFC recurrence and the concern that stents may act as a nidus for infections, especially if fragmentation occurs. In a randomized, controlled study from Europe, placing temporary or permanent transmural stents into PFCs, at a median follow-up of 14 months, no complications were encountered, although this was a short follow-up.39 In a case series of 22 patients with WOPN and DPDS from the United States, 3 recurrent symptomatic PFCs were encountered, all due to spontaneous stent migration at a median follow-up of 34 months.40 No infections were encountered in the patients with indwelling stents as was seen in our series as well. Infected PFCs developed only when there was loss of one or both transmural stents, with or without stent fragmentation. The 2 patients, who developed PFCs despite intact indwelling transgastric stents, had fluid collections approximately 3 to 592 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 3 : 2012
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4 cm each. We suspect that they are partially or intermittently decompressing through the transmural stents and hence not symptomatic or growing in size. Drain removal in our series was delayed in several early patients as the team erred on the side of safety, leaving percutaneous drains in place longer than might have been necessary. For the last 6 patients, drains were successfully removed within 2 weeks. Unless there is forthcoming data to guide us otherwise, the plan is to follow all patients with indwelling transmural stents indefinitely with 6 to 12 monthly visits and imaging studies to gain a perspective on the rates of stent migration, PFC formation, atrophy of the disconnected gland, and whether any such changes on imaging studies can predict future complications. There are several limitations to this study: (1) this was a highly selected group of patients who were managed by using 3 different techniques; (2) there was no comparative group such as surgical or radiologic control; and (3) this small group of patients was studied and followed for a relatively short median period of 25 months. In summary, the current article describes the successful use of 3 rendezvous techniques used at our institution to resolve EPFs associated with DPDS, after complete resolution of all PFCs. This precluded a difficult operation in all patients, demonstrating that good outcomes can be achieved even in difficult cases, when a group of aggressive interventional endoscopists and radiologists collaborate. Although there have been 4 mild-to-moderate adverse events, they have been successfully managed endoscopically or with an interventional radiology procedure, and there has been no mortality to date. The main limiting factor at this time is the spontaneous migration of stents leading to recurrent PFCs. Specially designed stents that will not migrate may help resolve this ongoing problem. The durability of these findings is contingent on larger case series and confirmation at other pancreatic centers.
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8. Ridgeway MG, Stabile BE. Surgical management and treatment of pancreatic fistulas. Surg Clin North Am 1996;76:1159-73. 9. Varadarajulu S, Noone TC, Tutuian R, et al. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc 2005;61:568-75. 10. Kozarek RA, Ball TJ, Patterson DJ, et al. Transpapillary stenting for pancreaticocutaneous fistulas. J Gastrointest Surg 1997;1:357-61. 11. Costamagna G, Mutignani M, Ingrosso M, et al. Endoscopic treatment of postsurgical external pancreatic fistulas. Endoscopy 2001;33:317-22. 12. Halttunen J, Weckman L, Kemppainen E, et al. The endoscopic management of pancreatic fistulas. Surg Endosc 2005;19:559-62. 13. Tann M, Maglinte D, Howard TH, et al. Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients. J Comput Assist Tomogr 2003;27:577-82. 14. Arvanitakis M, Delhaye M, Bali M, et al. Endoscopic treatment of external pancreatic fistulas: when draining the main pancreatic duct is not enough. Am J Gastroenterol 2007;102:516-24. 15. Fotoohi M, D’Agostino HB, Wollman B, et al. Persistent pancreatocutaneous fistula after percutaneous drainage of pancreatic fluid collections: role of cause and severity of pancreatitis. Radiology 1999;213: 573-8. 16. Uomo G, Molino D, Visconti M, et al. The incidence of main pancreatic duct disruption in severe biliary pancreatitis. Am J Surg 1998;176:49-52. 17. Ross A, Gluck M, Irani S, et al. Combined endoscopic and percutaneous drainage of organized pancreatic necrosis. Gastrointest Endosc 2010; 71:79-84. 18. Gluck M, Ross A, Irani S, et al. Endoscopic and percutaneous drainage of symptomatic walled-off pancreatic necrosis reduces hospital stay and radiographic resources. Clin Gastroenterol Hepatol 2010;8:1083-8. 19. Gluck M, Ross A, Irani S, et al. Dual modality drainage for symptomatic walled-off pancreatic necrosis reduces length of hospitalization, radiological procedures, and number of endoscopies compared to standard percutaneous drainage. J Gastrointest Surg 2012;16:248-57. 20. Lawrence C, Howell DA, Stefan AM, et al. Disconnected pancreatic tail syndrome: potential for endoscopic therapy and results of long-term follow-up. Gastrointest Endosc 2008;67:673-9. 21. Devière J, Bueso H, Baize M, et al. Complete disruption of the main pancreatic duct: endoscopic management. Gastrointest Endosc 1995;42: 445-51. 22. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010;71:446-54. 23. Bradley EL. A fifteen year experience with open drainage for infected pancreatic necrosis. Surg Gynecol Obstet 1993;177:215-22. 24. Harris JA, Jury RP, Catto J, et al. Closed drainage versus open packing of infected pancreatic necrosis. Am Surg 1995;61:612-7. 25. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362: 1491-502. 26. Freeny PC, Hauptmann E, Althaus SJ, et al. Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis. AJR Am J Roentgenol;170:969-75. 27. Echenique AM, Sleeman D, Yrizarry J, et al. Percutaneous catheterdirected debridement of infected pancreatic necrosis: results in 20 patients. J Vasc Interven Radiol 1998;9:565-71. 28. vanSonnenberg E, Wittich GR, Chon KS, et al. Percutaneous radiologic drainage of pancreatic abscesses. AJR Am J Roentgenol 1997;168:97984. 29. Ammori BJ. Laparoscopic transgastric pancreatic necrosectomy for infected pancreatic necrosis. Surg Endosc 2002;16;1362.
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30. Parekh D. Laparoscopic-assisted pancreatic necrosectomy. Arch Surg 2006;141:895-903. 31. Horvath K, Freeny P, Escallon J, et al. Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study. Arch Surg 2010;145: 817-25. 32. Seifert H, Wehrmann T, Schmitt T, et al. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000;356:653-5. 33. Baron TH, Thaggard WG, Morgan DE, et al. Endoscopic therapy for organized pancreatic necrosis. Gastroenterology 1996;111:755-64. 34. Siefert H, Biermer M, Schmitt W, et al. Transluminal endoscopic necrosectomy. Gut 2009;58:1260-6. 35. Seewald S, Brand B, Groth S, et al. Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate. Gastrointest Endosc 2004;59: 463-70. 36. Romano A, Spaggiari M, Masetti M, et al. A new endoscopic treatment for pancreatic fistula after distal pancreatectomy: case report and review of the literature. Gastrointest Endosc 2008;68:798-801. 37. Engler S, Dorlars D, Riemann JF. Endoscopic fibrin gluing of a pancreatic duct fistula following acute pancreatitis [in German, with English abstract]. Dtsch Med Wochenschr 1996;121:1396-400. 38. Labori KJ, Trondsen E, Buanes T, et al. Endoscopic sealing of pancreatic fistulas: four case reports and review of the literature. Scand J Gastroenterol 2009;44:1491-6. 39. Arvanitakis M, Delhaye M, Bali MA, et al. Pancreatic-fluid collections: a randomized controlled-trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007;65:609-19. 40. Varadarajulu S, Wilcox CM. Endoscopic placement of permanent indwelling transmural stents in disconnected pancreatic duct syndrome: Does benefit outweigh the risks? Gastrointest Endosc 2011;74:1408-12. Abbreviations: DPDS, disconnected pancreatic duct syndrome; EPF, external pancreatic fistula; PFC, pancreatic fluid collection; WOPN, walled-off pancreatic necrosis
Use your mobile device to scan this QR code and watch the author interview. Download a free QR code scanner by searching ‘QR Scanner’ in your mobile device’s app store. . DISCLOSURE: Virginia Mason Medical Center received an honorarium from Boston Scientific, Cook Medical, and Olympus America, Inc for a live endoscopy course. No other financial relationships relevant to this publication were disclosed. Copyright © 2012 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2012.05.006 Received March 8, 2012. Accepted May 4, 2012. Current affiliations: Digestive Disease Institute (1), Department of Radiology (2), Virginia Mason Medical Center, Department of Gastroenterology (3), Swedish Medical Center, Seattle, Washington, USA. Reprint requests: Shayan Irani, MBBS, MD, Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Ave, MS: C3-GAS, Seattle, WA 98111.
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TABLE 1. Preprocedural characteristics of patients with external pancreatic fistula (EPF) and disconnect pancreatic duct syndrome (DPDS) prior to rendezvous treatment
Patient No.
Age/Gender
Etiology of Pancreatitis
Associated Chronic Pancreatitis
EPF Location
EPF Duration (months)
EPF Output (ml/day)
EPF Discharge
(Outside-In) IR guided Trans-gastric/duodenal Internalization 1
59//M
Post ERCP
No
Genu
19
50
Serous
2
50/M
Hyper-triglyceridemia
No
Head
1
200
Purulent
3
52/F
Gallstone
No
Body
6
700
Serous
4
65/M
Post-operative
Yes
Genu
48
50
Serous
5
36/M
Gallstone
No
Genu
5
300
Serous
6
40/M
Gallstone
No
Genu
2
200
Serous
7
54/M
Medication
No
Body
24
200
Serous
8
28/F
Gallstone
No
Genu
30
200
Serous
9
47/M
Gallstone
No
Body
26
350
Serous
10
48/M
Idiopathic
No
Genu
5
200
Serous
(Inside-Out) Endoscopic Ultrasound guided Fistula Puncture 11
57/M
Post-ampullectomy
No
Body
3
200
Purulent
12
51/M
Alcohol
Yes
Body
3
250
Serous
13
24/M
Hyper-triglyceridemia
No
Genu
3
50
Serous
(Reconnecting the Disconnected Duct) IR guided Transpapillary Internalization 14
57/M
Idiopathic
No
Body
7
300
Purulent
15
54/F
Alcohol
Yes
Genu
2
300
Serous
5
200
Median
51
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TABLE 2. Procedural details of patients with external pancreatic fistula (EPF) and disconnect pancreatic duct syndrome (DPDS) treated with three rendezvous techniques Patient No.
Sedation
Endoscope Used
Stent Route
Stents Used
Procedure Time (mins)
No. of Procedures
(Outside-In) IR guided Trans-gastric/duodenal Puncture 1
CS
Duodenoscope
Transgastric
7Fr X 7cm, 7Fr X 10cm
75
2
2
CS
Linear EUS ⫹ Duodenoscope
Transduodenal
7Fr X 3cm, 7Fr X 5cm
80
1
3
CS
Duodenoscope
Transgastric
7 Fr X 5cm
45
1
4
GA
Duodenoscope
Transgastric
7Fr X 5cm, 7Fr X 7cm (straight)
40
1
5
CS
Linear EUS ⫹ Duodenoscope
Transgastric
7Fr X 5cm, 7Fr X 5cm
100
1
6
CS
Duodenoscope
Transgastric
7Fr X 3cm, 7Fr X 3cm
70
1
7
GA
Duodenoscope
Transgastric
7Fr X 5cm, 7Fr X 3cm
70
1
8
GA
Duodenoscope
Transgastric
7Fr X 3cm, 7Fr X 3cm
65
1
9
GA
Duodenoscope
Transgastric
7Fr X 3cm, 7Fr X 3cm
50
1
10
GA
Duodenoscope
Transgastric
7Fr X 3cm, 7Fr X 3cm
60
1
(Inside-Out) Endoscopic Ultrasound guided Fistula Puncture 11
GA
Linear EUS ⫹ Duodenoscope
Transgastric
7Fr X 5cm, 7Fr X 5cm
60
1
12
GA
Linear EUS ⫹ Duodenoscope
Transgastric
7Fr X 3cm, 7Fr X 3cm
50
1
13
GA
Linear EUS
Transgastric
10Fr X 3cm
90
1
(Reconnecting the disconnected duct) IR guided Transpapillary Internalization 14
GA
Linear EUS ⫹ Duodenoscope
Transpapillary
7Fr X 12cm (straight)
65
1
15
CS
Duodenoscope
Transpapillary
5Fr X 12cm, 5Fr X 9cm.(straight)
60
1
65
1
Median CS, Conscious sedation; GA, general anesthesia.
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TABLE 3. Postprocedural Results of patients with external pancreatic fistula (EPF) and disconnect pancreatic duct syndrome (DPDS) treated with three rendezvous techniques
Patient No.
Time for EPF closure (days)
EPF Recurrence
New PFC Formation
Loss of Transenteral stents
Follow up (months)
Adverse Events & Treatment
(Outside-In) IR guided Trans-gastric/duodenal Puncture 1
20
No
Yes
1 of 2 stents
113
Stent fragmentation & infected pseudocyst. IR drain ⫹ EUS cystgastrostomy.
2
42
No
Yes
2 of 2 stents
61
Infected pseudocyst. IR drain ⫹ EUS/ERP pancreaticoduodenostomy.
3
1
No
No
No
37
None
4
7
No
No
1 of 2 stents
36
None
5
21
No
No
No
36
None
6
46
No
No
No
22
None
7
1
No
No
No
15
None
8
2
No
Yes
No
14
None
9
1
No
No
No
10
None
10
2
No
No
No
6
Post-procedure fever. Antibiotics.
(Inside-Out) Endoscopic Ultrasound guided Fistula Puncture 11
73
No
No
No
25
None
12
1
No
Yes
No
16
None
13
10
No
Yes
1 of 1 stent
16
Infected pseudocyst. EUS cystgastrostomy
(Reconnecting the Disconnected Duct) IR guided Transpapillary Internalization 14
53
No
No
No
48
None
15
5
No
No
No
42
None
Median
7
25
PFC, Pancreatic fluid collection.
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Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video) Shayan Irani, MD,1 Michael Gluck, MD,1 Andrew Ross, MD,1 S. Ian Gan, MD,1 Robert Crane, MD,2 John J. Brandabur, MD,3 Ellen Hauptmann, MD,2 Mehran Fotoohi, MD,2 Richard A. Kozarek, MD1 Seattle, Washington, USA
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. (Gastrointest Endosc 2012;76:586-93.) (footnotes appear on last page of article)
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A pancreatic fistula can result from several causes, including pancreatic surgery,1-3 surgery near the pancreas,4,5 and as a consequence of severe pancreatitis.6 An external pancreatic fistula (EPF), also known as a pancreaticocutaneous fistula, is generally the result of an iatrogenic manipulation (percutaneous or operative) of a pancreatic fluid collection (PFC), especially walled-off pancreatic necrosis (WOPN). The 3 basic tenets of management of pancreatic fistulas are stabilization and medical optimization, understanding the anatomy of the ductal disruption, and the definitive management of the fistula (medical, endoscopic, or surgical). Medical management consisting of fasting, nutritional support, and octreotide usually is slow to work and rarely is effective by itself.7 Traditionally, after failed medical management, surgery was the next treatment option, but surgery is associated with a high morbidity and mortality.8 Endoscopic management of EPFs was developed as a less invasive approach but is dependent on an intact main pancreatic duct to allow resolution of the fistula by reducing the downstream pressure gradient across the papilla into the duodenum by means of transpapillary stenting.9-12 Acute necrotizing pancreatitis and WOPN often result in main pancreatic duct disruption, often leaving a fair amount of functional pancreas upstream of the complete disconnection (disconnected pancreatic duct syndrome [DPDS]).13 Transpapillary drainage alone is not adequate in such situations. Percutaneous or surgical drainage of WOPN in this setting provides a low-pressure system to the outside that resolves the fluid collection. Unfortunately, these drains perpetuate the flow of pancreatic juice externally, occasionally resulting in a high-output EPFs that can drain upward of 400 mL/day.14 Multiple case series in which patients were treated with external drainage of WOPN note a rate of DPDS approaching 50%, resulting in high EPF rates.15,16 Patients with persistent EPFs are left with the option of a long-term percutaneous drain (a major inconvenience and predisposing factor for infection) or surgery (distal pancreatectomy) that is associated with significant morbidity and mortality in this setting because of adhesions, splenic vein thrombosis, and varices.8 In prior case series,17-19 our team has described a combined endoscopic and percutaneous drainage of symptomatic WOPN called dual modality drainage. By placing transgastric or transduodenal stents into WOPN at the time of percutaneous drainage, we were able to avoid the development of EPFs in all patients by diverting the pancreatic juice from the disconnected gland enterally. There have been prior case series describing the management of DPDS with existing PFCs,20,21 where transmural drainage of the PFCs alone was able to provide drainage for the disconnected pancreatic gland. However, in the absence of a PFC to target for endoscopic drainage, management of a fistula without a fluid collection can be even more challenging. With the prinwww.giejournal.org
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Take-home Message ●
The authors describe the successful use of 3 endoscopic and percutaneous rendezvous techniques to resolve external pancreatic fistulas associated with a disconnected pancreatic duct syndrome, precluding a difficult operation in all patients, with minimal morbidity and no mortality.
cipal goal in mind of diverting pancreatic juice enterally, we developed an approach to treat persistent EPFs in patients with DPDS after complete resolution of all PFCs by using a combined endoscopic and percutaneous rendezvous approach to avoid the need for surgery. We present our data on managing 15 such patients by using 3 different rendezvous techniques.
PATIENTS AND METHODS Patients From October 2002 to October 2011, 15 patients (12 men) with EPFs and DPDS resulting from WOPN were treated at our institution. Three patients were identified retrospectively from an internal review board–approved database, and the other 12 were included prospectively. All patients were followed after the procedures with clinic visits and imaging studies. This study was approved by the internal review board at our institution. The median age of the patients was 51 years (range 24-65 years). Patients developed persistent EPFs as a consequence of manipulation (surgical 4, percutaneous 11) of WOPN. The treated fluid collections had resolved completely, and attempts to remove the percutaneous drains had failed by using conservative measures. All patients had DPDS based on endoscopic retrograde pancreatography. There was viable pancreatic parenchyma in the body and/or tail of the pancreas based on cross-sectional imaging (CT and or MRCP) and persistent high levels of amylase fluid (⬎20,000 units/L) in the drainage catheters. Patients with fistula outputs of ⬍200 mL/day were given a chance for spontaneous fistula closure with total parenteral nutrition or jejunal elemental nutrition and/or a trial of octreotide. All patients were deemed poor surgical candidates or refused surgery (Table 1, available online at www.giejournal.org). Prior attempts at fistula drainage via EUS alone had failed in 2 patients because of the inability to obtain enough wire purchase in the fistulous tract to dilate through tract scarring (consequence of the healed WOPN) to allow for the placement of transgastric stents.
Definitions An EPF was defined as the presence of a tract leading from the pancreatic duct to the abdominal or chest wall. Volume 76, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 587
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Figure 1. Disconnected pancreatic duct syndrome. A, Complete cutoff of the pancreatic duct (large arrow). B, Blowout of the pancreatic duct (large arrow).
DPDS was defined as a cutoff (n ⫽ 13) or blowout (n ⫽ 2) of the pancreatic duct, with the inability to demonstrate upstream the body/tail of the pancreas on a pancreatogram (Fig. 1). The upstream disconnected body/tail of the pancreas was the source of the EPF in all cases and was identified at fistulogram or MRCP. Persistence of the EPF was determined by fistula output in excess of 50 mL/day, with amylase levels greater than 20,000 units/L and no residual WOPN on CT scanning. Successful closure of the EPF was defined by the ability to remove the percutaneous drain without any further pancreatic juice draining to the skin, and the time to closure was defined as the days required to achieve success. Number of procedures was defined by the quantity of rendezvous procedures performed to achieve success. A recurrent PFC was defined as formation of a fluid collection after removal of the percutaneous drains.
Technique After stabilization of the patient and optimal patient medical condition, interventional radiologists and therapeutic gastroenterologists conferred after jointly reviewing imaging study results (CT, MRCP, fistulogram, and endoscopic retrograde pancreatography) on each patient to determine the optimal route for transenteral fistula creation to divert the pancreatic juice enterally. Careful attention was paid to the size and location of varices potentially in the path of the internalization tract. Patients received antibiotics before the procedure and were allowed a lowfat diet as tolerated after the procedure. Outside-in interventional radiologist– guided transgastric/duodenal puncture (n ⴝ 10). This was the preferred technique and has been reported previously in 1 prior case series.14 The existing EPF in which the percutaneous catheter resided was assessed for proximity 588 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 3 : 2012
to the stomach/duodenum, and a path into the GI lumen that was free of any vasculature was determined. A stiff wire (Amplatz stiff wire; Cook Medical, Winston-Salem, NC) was advanced through the existing percutaneous tract to the site of pancreatic duct disruption and was manipulated to approximate the gastric/duodenal wall. A duodenoscope was used to insufflate the stomach/ duodenum. The radiologist then punctured the gastric/ duodenal wall (under fluoroscopic and endoscopic guidance) by using a transjugular intrahepatic portosystemic shunt needle (angled needle catheter combination; Cook Medical, Winston-Salem, NC). A flexible 0.035 Jagwire (Boston Scientific, Natick, Mass) was then delivered percutaneously through the needle, captured, and brought out of the endoscope. Over that working wire, the radiologist then delivered a 6.5F, Lieberman introducer (Cook Medical) through which a second wire was advanced, then similarly captured and brought out of the endoscope. With two wires secured at both ends (endoscopically by the gastroenterologist and percutaneously by the radiologist) the gastric/duodenal tract was balloon dilated to 8 or 10 mm under fluoroscopic guidance. Two double-pigtail stents were then delivered into the fistula tract adjacent to the pancreatic ductal disruption with the proximal portions deployed in the gastric/ duodenal lumen (Table 2, available online at www.giejournal.org). The radiologist then left a safety drain in the portion of the EPF between the ductal disruption and the skin, through which contrast material was injected to assure adequate diversion into the gastric/duodenal lumen. After that injection, the drainage catheter was capped to encourage flow into the stomach/duodenum (Fig. 2). Inside-out EUS-guided fistula puncture (n ⴝ 3). This technique was used in 2 patients with very large varices in the expected tract of the needle puncture by the www.giejournal.org
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Figure 2. Outside-in interventional radiology– guided transgastric puncture. A, Disconnected pancreatic tail outlined at fistulogram. B, Catheter over stiff wire advanced to gastric lumen. C, and D, Transjugular intrahepatic portosystemic shunt (TIPSS) needle used to puncture gastric wall. E, and F, Wire passed through TIPSS needle and pulled through the endoscope. G, and H, Two double-pigtail stents deployed in fistula. I, Finally, a fistulogram through a safety drain confirms diversion through stents to the gastric lumen.
radiologist and in 1 patient in whom the direction of the needle puncture led away from the gastric lumen, precluding the outside-in approach. A linear array echoendoscope with Doppler (Olympus America, Inc, Center Valley, Pa) was used to assess and avoid varices and to perform a transgastric puncture (19-gauge needle) of the fistula toward the percutaneous drain. A 0.035 Jagwire (Boston Scientific, Natick, MA) was advanced through the needle into the fistula tract. The radiologist exchanged the drain for a 5F catheter through which a wire basket was used to snare the Jagwire under fluoroscopic guidance and pull it through the existing EPF tract. Having secured the wire at www.giejournal.org
both ends (percutaneous through the EPF and transgastric through the echoendoscope), we repeated steps as described earlier with the radiologist advancing a second wire through the echoendoscope, balloon dilation of the fistula, and placement of two transgastric stents (Video 1, available online at www.giejournal.org). Reconnecting the disconnected duct: interventional radiologist– guided transpapillary access and internalization (n ⴝ 2). If the radiologist had been able to demonstrate an upstream (toward the tail) and downstream (toward the duodenum) pancreatic duct on prior fistulograms, the goal of the rendezvous procedure was Volume 76, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 589
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Figure 3. Reconnecting the disconnected ducts. Interventional radiology-guided transpapillary rendezvous. A, Unable to demonstrate upstream pancreatic duct in body/tail via transpapillary pancreatogram. B, Fistulogram able to demonstrate disconnected body/tail and downstream, pancreatic duct. C, A wire passed downstream through the papilla percutaneously. D, Wire grasped endoscopically and papillotome pulled into the fistulous tract. E, and F, Transpapillary completion pancreatogram followed by wire advancement to disconnected tail performed for the first time.
to bridge the disconnection and reconnect the disconnected ducts. In performing this technique, the radiologist passed a thin, flexible wire (0.025 Glidewire; Terumo Corp, Tokyo, Japan) in an antegrade fashion from the ductal disruption where the previously placed drainage catheter resided and managed to manipulate the wire through the papilla. The wire was captured by the endoscopist and brought out of the duodenoscope. Over that wire, a papillotome was negotiated through the end of the pancreatic duct into the fistulous tract, something that had failed in prior attempts at endoscopic retrograde pancreatography alone. A complete pancreatogram was achieved by transpapillary injection for the first time, and a transpapillary wire was advanced into the upstream tail of the pancreas through the papillotome, over which balloon dilation of the fistula (now a new stricture) was performed. One or two straight transpapillary pancreatic duct stents were deployed to reconnect the disconnected ducts (Fig. 3).
Follow-up Patients were admitted overnight for observation and were discharged home the following day with the percutaneous drain capped and instructions to flush the drain 590 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 3 : 2012
twice daily with 10 mL of sterile normal saline solution. Rarely, the external drains were left to gravity for a few days if initial output was high or if infection was suspected. A CT scan was obtained in 2 to 4 weeks. If no new PFCs developed, and the drainage catheters produced less than 20 mL/day, implying adequacy of the internalization process, the external drain was removed. Patients were followed in the gastroenterology clinic every 3 to 6 months for the first year and then every 6 to 12 months for symptom assessment and cross-sectional imaging (CT or MRCP). For patients who were managed with transpapillary stenting, endoscopic retrograde pancreatography was performed twice more on each patient, to exclude exchange and eventual removal of the pancreatic duct stents over the ensuing year.
RESULTS Fifteen patients (12 men), median age 51 years (range 24-65 years), with persistent EPFs (median 5 months, range 1-48 months) and DPDS, after complete resolution of all PFCs resulting from severe necrotizing pancreatitis underwent 1 of 3 rendezvous procedures to eliminate the www.giejournal.org
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EPFs. The median EPF output was 200 mL/day (range 50-700 mL/day). Choledocholithiasis was the etiology of the pancreatitis in one-third of the patients. The other causes included alcohol use (14%), post-ERCP or ampullectomy state (14%), hypertriglyceridemia (14%), and other causes (28%). Three of 15 (20%) patients had a history of chronic pancreatitis. Ductal disruption occurred at the genu in 8 patients (54%) and in the body of the pancreatic duct in 7 patients (46%). Only 3 patients (20%) had purulent-appearing drainage at the time of the rendezvous procedure, whereas the rest had clear, serous drainage; all were amylase rich (⬎20,000 units/L). Pancreatography was performed in all 15 patients, demonstrating a complete main pancreatic duct cutoff (n ⫽ 13) or blowout/leak without demonstration of the upstream pancreatic duct in the body/tail (n ⫽ 2). These 2 patients were managed with transpapillary rendezvous. The median number of procedures performed on each patient was 1, and the median procedure time was 65 minutes (range 40-100 minutes). Only 1 patient needed two procedures to achieve successful closure of the EPF. A second procedure was performed to optimally place the second transgastric stent and, parenthetically, the patient also had a demonstrated colon fistula to the pancreatic bed that rapidly closed with diversion of pancreatic juice to the stomach. The 2 patients treated with transpapillary rendezvous had 2 more ERCPs each after closure of the EPFs, prior to successful removal of the pancreatic duct stents over the ensuing year (Tables 2 and 3, available online at www.giejournal.org). Successful closure of the EPF was achieved in all 15 patients at a median time of 7 days (range 1-73 days). There was no recurrence of EPF in any of the 15 patients at a median follow-up period of 25 months (range 6-113 months). Adverse events were graded as mild, moderate, and severe22 and occurred in 4 of 15 patients (27%). There has been no mortality, to date. One patient developed postprocedural fever that resolved with 7 days of oral antibiotics, requiring 2 additional hospital days (mild adverse event). Five patients developed a new PFC, of which 2 were asymptomatic (observed on follow-up cross-sectional imaging). Four patients had spontaneous migration of one or both transmural stents, of which 3 developed a new symptomatic PFC. They presented with an infected pseudocyst (fever and abdominal pain) at 68, 31, and 11 months, respectively. In 1 of these patients, the pigtail portion of the stent had fragmented in the fistula, whereas the remainder of the stent had spontaneously migrated out. Two of the 3 patients with infected pseudocysts were treated, in addition to antibiotics, with new percutaneous drains and EUS cystgastrostomy (including removal of the stent fragments by the interventional radiologist), and 1 was managed with EUS cystgastrostomy alone (moderate adverse event). To re-establish drainage of the disconnected gland in the third patient, an EUS-guided endowww.giejournal.org
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scopic retrograde pancreatography was performed to place a pancreatic duct stent through the existing duodenal fistula (site of prior transduodenal stents) into the dorsal pancreatic duct. The patient repeatedly declined surgery and hence was managed with two subsequent stent changes over the next year, with no PFC recurrences (stent-free follow-up at 14 months). The 2 asymptomatic patients, who developed small PFCs, had both their transmural stents intact.
DISCUSSION One of the most common causes of EPF is iatrogenic manipulation of symptomatic WOPN. The management of the latter has evolved from open surgical debridement23,24 to using less invasive techniques with substantially lower morbidity and mortality rates,25 such as percutaneous drainage by radiologists,26-28 minimally invasive surgery to include laparoscopic or video-assisted retroperitoneal dissection,29-31 direct endoscopic necrosectomy,32-34 and dual modality drainage,17-19 which combines endoscopic placement of transenteral stents with percutaneous drainage catheters. However, any management of WOPN that does not involve a transenteric route (transgastric necrosectomy and dual modality drainage) is associated with a significant risk for EPFs that persists as long as the upstream disconnected pancreas (DPDS) continues to drain into a lower pressure system through the percutaneous drain out to the skin. The persistent EPFs aggravate patients’ conditions, can persist for months to years, and could occlude required expedient exchanges to avoid serious infections. Definitive surgery (distal pancreatectomy) has a significant morbidity and defined mortality.8 Interventional radiologists have attempted EPF closure by injecting tissue adhesives such as fibrin glue and cyanoacrylate.35-38 Limitations of this technique include the need for recurrent injections, acute pancreatitis associated with cyanoacrylate, infections, and failures that have been attributed to ongoing active inflammation and pancreatitis. In addition, this method does not provide a drainage solution for the functional, disconnected pancreatic gland, which can result in the recurrence of the EPF or the formation of a new PFC.35,38 As an alternative to surgery or attempt at fistula closure by interventional radiology, a rendezvous endoscopic and percutaneous approach can be used to direct pancreatic secretions back into the intestinal lumen via transenteral stents, thus allowing for closure of the EPF by providing a new path of lower resistance for pancreatic juice. This allows closure of the EPF, prevents its recurrence or the development of a new PFC, and potentially preserves parenchymal function of the disconnected gland. To the best of our knowledge, there is only one prior case series14 describing 16 patients with persistent EPFs of various causes, including postoperative causes, who benefited by internalization of the pancreatic fistula done by use of an Volume 76, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 591
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endoscopic means alone or a rendezvous approach. This series, however, included 7 patients with PFCs larger than 3 cm that were treated endoscopically alone and 6 patients with leakage of a branch duct or partial main duct. Only 5 patients had no PFCs and a complete DPDS, similar to all 15 in our group (what we consider the most difficult group to treat), who were treated by a rendezvous technique. The first patient treated in the current study was in 2002, and dual modality drainage was introduced in 2007. Since 2007, we have performed dual modality drainage in over 70 patients without a single case of EPF despite a 50% incidence of DPDS. Unfortunately, some patients with WOPN do not have safe endoscopic routes for the placement of transenteral stents because of the lack of proximity to the stomach/duodenum, a need for early drainage due to early uncontrolled infections, or rarely, because of intervening varices. For these patients as well as those who had percutaneous drains placed at institutions that do not place transenteral endoprostheses, we have used the 3 rendezvous techniques described earlier to successfully resolve all EPFs without any recurrence at a median follow-up of 25 months. The described rendezvous techniques are not free of adverse events. Four of 15 patients (27%) had mild to moderate adverse events, 3 of whom required another intervention. However, there has been no mortality to date. The development of a new PFC was related to the loss of one or both transmural stents. This suggests that a single stent often will be inadequate to provide long-term drainage because of stent occlusion, and, thus, two stents provide drainage by allowing “wicking” between the prostheses. Pancreaticogastric fistulae will close in the absence of a simple patent prosthesis to maintain patency to the disconnected pancreatic gland. This has been demonstrated in prior studies, including a randomized trial from Europe that compared temporary and permanent stents for transmural drainage of PFCs. This study found that stent removal was associated with higher rates of PFC recurrence.39 Two of the concerns of permanent indwelling transmural prostheses are that stent occlusion or migration could lead to PFC recurrence and the concern that stents may act as a nidus for infections, especially if fragmentation occurs. In a randomized, controlled study from Europe, placing temporary or permanent transmural stents into PFCs, at a median follow-up of 14 months, no complications were encountered, although this was a short follow-up.39 In a case series of 22 patients with WOPN and DPDS from the United States, 3 recurrent symptomatic PFCs were encountered, all due to spontaneous stent migration at a median follow-up of 34 months.40 No infections were encountered in the patients with indwelling stents as was seen in our series as well. Infected PFCs developed only when there was loss of one or both transmural stents, with or without stent fragmentation. The 2 patients, who developed PFCs despite intact indwelling transgastric stents, had fluid collections approximately 3 to 592 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 3 : 2012
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4 cm each. We suspect that they are partially or intermittently decompressing through the transmural stents and hence not symptomatic or growing in size. Drain removal in our series was delayed in several early patients as the team erred on the side of safety, leaving percutaneous drains in place longer than might have been necessary. For the last 6 patients, drains were successfully removed within 2 weeks. Unless there is forthcoming data to guide us otherwise, the plan is to follow all patients with indwelling transmural stents indefinitely with 6 to 12 monthly visits and imaging studies to gain a perspective on the rates of stent migration, PFC formation, atrophy of the disconnected gland, and whether any such changes on imaging studies can predict future complications. There are several limitations to this study: (1) this was a highly selected group of patients who were managed by using 3 different techniques; (2) there was no comparative group such as surgical or radiologic control; and (3) this small group of patients was studied and followed for a relatively short median period of 25 months. In summary, the current article describes the successful use of 3 rendezvous techniques used at our institution to resolve EPFs associated with DPDS, after complete resolution of all PFCs. This precluded a difficult operation in all patients, demonstrating that good outcomes can be achieved even in difficult cases, when a group of aggressive interventional endoscopists and radiologists collaborate. Although there have been 4 mild-to-moderate adverse events, they have been successfully managed endoscopically or with an interventional radiology procedure, and there has been no mortality to date. The main limiting factor at this time is the spontaneous migration of stents leading to recurrent PFCs. Specially designed stents that will not migrate may help resolve this ongoing problem. The durability of these findings is contingent on larger case series and confirmation at other pancreatic centers.
REFERENCES 1. Baker RJ, Bass RT, Zajtchuk R, et al. External pancreatic fistula following abdominal injury. Arch Surg 1967;95:556-66. 2. Alexakis N, Sutton R, Neoptolemos JP. Surgical treatment of pancreatic fistula. Dig Surg 2004;21:262-74. 3. Tsiotos GG, Smith CD, Sarr MG. Incidence and management of pancreatic and enteric fistulas after surgical management of severe necrotizing pancreatitis. Arch Surg 1995;130:48-52. 4. McCulloch P, Ward J, Tekkis PP, et al. Mortality and morbidity in gastroesophageal cancer surgery: initial results of ASCOT multicenter prospective cohort study. BMJ 2003;327:1192-8. 5. Chand B, Walsh RM, Ponsky J, et al. Pancreatic complications following laparoscopic splenectomy. Surg Endosc 1999;13:1220-5. 6. Neff R. Pancreatic pseudocyst and fluid collections: percutaneous approaches. Surg Clin North Am 2001;81:399-403. 7. Li-Ling J, Irving M. Somatostatin and octreotide in the prevention of postoperative pancreatic complications and the treatment of enterocutaneous pancreatic fistulas: a systematic review of randomized controlled trials. Br J Surg 2001;88:190-9.
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8. Ridgeway MG, Stabile BE. Surgical management and treatment of pancreatic fistulas. Surg Clin North Am 1996;76:1159-73. 9. Varadarajulu S, Noone TC, Tutuian R, et al. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc 2005;61:568-75. 10. Kozarek RA, Ball TJ, Patterson DJ, et al. Transpapillary stenting for pancreaticocutaneous fistulas. J Gastrointest Surg 1997;1:357-61. 11. Costamagna G, Mutignani M, Ingrosso M, et al. Endoscopic treatment of postsurgical external pancreatic fistulas. Endoscopy 2001;33:317-22. 12. Halttunen J, Weckman L, Kemppainen E, et al. The endoscopic management of pancreatic fistulas. Surg Endosc 2005;19:559-62. 13. Tann M, Maglinte D, Howard TH, et al. Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients. J Comput Assist Tomogr 2003;27:577-82. 14. Arvanitakis M, Delhaye M, Bali M, et al. Endoscopic treatment of external pancreatic fistulas: when draining the main pancreatic duct is not enough. Am J Gastroenterol 2007;102:516-24. 15. Fotoohi M, D’Agostino HB, Wollman B, et al. Persistent pancreatocutaneous fistula after percutaneous drainage of pancreatic fluid collections: role of cause and severity of pancreatitis. Radiology 1999;213: 573-8. 16. Uomo G, Molino D, Visconti M, et al. The incidence of main pancreatic duct disruption in severe biliary pancreatitis. Am J Surg 1998;176:49-52. 17. Ross A, Gluck M, Irani S, et al. Combined endoscopic and percutaneous drainage of organized pancreatic necrosis. Gastrointest Endosc 2010; 71:79-84. 18. Gluck M, Ross A, Irani S, et al. Endoscopic and percutaneous drainage of symptomatic walled-off pancreatic necrosis reduces hospital stay and radiographic resources. Clin Gastroenterol Hepatol 2010;8:1083-8. 19. Gluck M, Ross A, Irani S, et al. Dual modality drainage for symptomatic walled-off pancreatic necrosis reduces length of hospitalization, radiological procedures, and number of endoscopies compared to standard percutaneous drainage. J Gastrointest Surg 2012;16:248-57. 20. Lawrence C, Howell DA, Stefan AM, et al. Disconnected pancreatic tail syndrome: potential for endoscopic therapy and results of long-term follow-up. Gastrointest Endosc 2008;67:673-9. 21. Devière J, Bueso H, Baize M, et al. Complete disruption of the main pancreatic duct: endoscopic management. Gastrointest Endosc 1995;42: 445-51. 22. Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010;71:446-54. 23. Bradley EL. A fifteen year experience with open drainage for infected pancreatic necrosis. Surg Gynecol Obstet 1993;177:215-22. 24. Harris JA, Jury RP, Catto J, et al. Closed drainage versus open packing of infected pancreatic necrosis. Am Surg 1995;61:612-7. 25. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med 2010;362: 1491-502. 26. Freeny PC, Hauptmann E, Althaus SJ, et al. Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis. AJR Am J Roentgenol;170:969-75. 27. Echenique AM, Sleeman D, Yrizarry J, et al. Percutaneous catheterdirected debridement of infected pancreatic necrosis: results in 20 patients. J Vasc Interven Radiol 1998;9:565-71. 28. vanSonnenberg E, Wittich GR, Chon KS, et al. Percutaneous radiologic drainage of pancreatic abscesses. AJR Am J Roentgenol 1997;168:97984. 29. Ammori BJ. Laparoscopic transgastric pancreatic necrosectomy for infected pancreatic necrosis. Surg Endosc 2002;16;1362.
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30. Parekh D. Laparoscopic-assisted pancreatic necrosectomy. Arch Surg 2006;141:895-903. 31. Horvath K, Freeny P, Escallon J, et al. Safety and efficacy of video-assisted retroperitoneal debridement for infected pancreatic collections: a multicenter, prospective, single-arm phase 2 study. Arch Surg 2010;145: 817-25. 32. Seifert H, Wehrmann T, Schmitt T, et al. Retroperitoneal endoscopic debridement for infected peripancreatic necrosis. Lancet 2000;356:653-5. 33. Baron TH, Thaggard WG, Morgan DE, et al. Endoscopic therapy for organized pancreatic necrosis. Gastroenterology 1996;111:755-64. 34. Siefert H, Biermer M, Schmitt W, et al. Transluminal endoscopic necrosectomy. Gut 2009;58:1260-6. 35. Seewald S, Brand B, Groth S, et al. Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate. Gastrointest Endosc 2004;59: 463-70. 36. Romano A, Spaggiari M, Masetti M, et al. A new endoscopic treatment for pancreatic fistula after distal pancreatectomy: case report and review of the literature. Gastrointest Endosc 2008;68:798-801. 37. Engler S, Dorlars D, Riemann JF. Endoscopic fibrin gluing of a pancreatic duct fistula following acute pancreatitis [in German, with English abstract]. Dtsch Med Wochenschr 1996;121:1396-400. 38. Labori KJ, Trondsen E, Buanes T, et al. Endoscopic sealing of pancreatic fistulas: four case reports and review of the literature. Scand J Gastroenterol 2009;44:1491-6. 39. Arvanitakis M, Delhaye M, Bali MA, et al. Pancreatic-fluid collections: a randomized controlled-trial regarding stent removal after endoscopic transmural drainage. Gastrointest Endosc 2007;65:609-19. 40. Varadarajulu S, Wilcox CM. Endoscopic placement of permanent indwelling transmural stents in disconnected pancreatic duct syndrome: Does benefit outweigh the risks? Gastrointest Endosc 2011;74:1408-12. Abbreviations: DPDS, disconnected pancreatic duct syndrome; EPF, external pancreatic fistula; PFC, pancreatic fluid collection; WOPN, walled-off pancreatic necrosis
Use your mobile device to scan this QR code and watch the author interview. Download a free QR code scanner by searching ‘QR Scanner’ in your mobile device’s app store. . DISCLOSURE: Virginia Mason Medical Center received an honorarium from Boston Scientific, Cook Medical, and Olympus America, Inc for a live endoscopy course. No other financial relationships relevant to this publication were disclosed. Copyright © 2012 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2012.05.006 Received March 8, 2012. Accepted May 4, 2012. Current affiliations: Digestive Disease Institute (1), Department of Radiology (2), Virginia Mason Medical Center, Department of Gastroenterology (3), Swedish Medical Center, Seattle, Washington, USA. Reprint requests: Shayan Irani, MBBS, MD, Digestive Disease Institute, Virginia Mason Medical Center, 1100 9th Ave, MS: C3-GAS, Seattle, WA 98111.
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TABLE 1. Preprocedural characteristics of patients with external pancreatic fistula (EPF) and disconnect pancreatic duct syndrome (DPDS) prior to rendezvous treatment
Patient No.
Age/Gender
Etiology of Pancreatitis
Associated Chronic Pancreatitis
EPF Location
EPF Duration (months)
EPF Output (ml/day)
EPF Discharge
(Outside-In) IR guided Trans-gastric/duodenal Internalization 1
59//M
Post ERCP
No
Genu
19
50
Serous
2
50/M
Hyper-triglyceridemia
No
Head
1
200
Purulent
3
52/F
Gallstone
No
Body
6
700
Serous
4
65/M
Post-operative
Yes
Genu
48
50
Serous
5
36/M
Gallstone
No
Genu
5
300
Serous
6
40/M
Gallstone
No
Genu
2
200
Serous
7
54/M
Medication
No
Body
24
200
Serous
8
28/F
Gallstone
No
Genu
30
200
Serous
9
47/M
Gallstone
No
Body
26
350
Serous
10
48/M
Idiopathic
No
Genu
5
200
Serous
(Inside-Out) Endoscopic Ultrasound guided Fistula Puncture 11
57/M
Post-ampullectomy
No
Body
3
200
Purulent
12
51/M
Alcohol
Yes
Body
3
250
Serous
13
24/M
Hyper-triglyceridemia
No
Genu
3
50
Serous
(Reconnecting the Disconnected Duct) IR guided Transpapillary Internalization 14
57/M
Idiopathic
No
Body
7
300
Purulent
15
54/F
Alcohol
Yes
Genu
2
300
Serous
5
200
Median
51
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TABLE 2. Procedural details of patients with external pancreatic fistula (EPF) and disconnect pancreatic duct syndrome (DPDS) treated with three rendezvous techniques Patient No.
Sedation
Endoscope Used
Stent Route
Stents Used
Procedure Time (mins)
No. of Procedures
(Outside-In) IR guided Trans-gastric/duodenal Puncture 1
CS
Duodenoscope
Transgastric
7Fr X 7cm, 7Fr X 10cm
75
2
2
CS
Linear EUS ⫹ Duodenoscope
Transduodenal
7Fr X 3cm, 7Fr X 5cm
80
1
3
CS
Duodenoscope
Transgastric
7 Fr X 5cm
45
1
4
GA
Duodenoscope
Transgastric
7Fr X 5cm, 7Fr X 7cm (straight)
40
1
5
CS
Linear EUS ⫹ Duodenoscope
Transgastric
7Fr X 5cm, 7Fr X 5cm
100
1
6
CS
Duodenoscope
Transgastric
7Fr X 3cm, 7Fr X 3cm
70
1
7
GA
Duodenoscope
Transgastric
7Fr X 5cm, 7Fr X 3cm
70
1
8
GA
Duodenoscope
Transgastric
7Fr X 3cm, 7Fr X 3cm
65
1
9
GA
Duodenoscope
Transgastric
7Fr X 3cm, 7Fr X 3cm
50
1
10
GA
Duodenoscope
Transgastric
7Fr X 3cm, 7Fr X 3cm
60
1
(Inside-Out) Endoscopic Ultrasound guided Fistula Puncture 11
GA
Linear EUS ⫹ Duodenoscope
Transgastric
7Fr X 5cm, 7Fr X 5cm
60
1
12
GA
Linear EUS ⫹ Duodenoscope
Transgastric
7Fr X 3cm, 7Fr X 3cm
50
1
13
GA
Linear EUS
Transgastric
10Fr X 3cm
90
1
(Reconnecting the disconnected duct) IR guided Transpapillary Internalization 14
GA
Linear EUS ⫹ Duodenoscope
Transpapillary
7Fr X 12cm (straight)
65
1
15
CS
Duodenoscope
Transpapillary
5Fr X 12cm, 5Fr X 9cm.(straight)
60
1
65
1
Median CS, Conscious sedation; GA, general anesthesia.
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TABLE 3. Postprocedural Results of patients with external pancreatic fistula (EPF) and disconnect pancreatic duct syndrome (DPDS) treated with three rendezvous techniques
Patient No.
Time for EPF closure (days)
EPF Recurrence
New PFC Formation
Loss of Transenteral stents
Follow up (months)
Adverse Events & Treatment
(Outside-In) IR guided Trans-gastric/duodenal Puncture 1
20
No
Yes
1 of 2 stents
113
Stent fragmentation & infected pseudocyst. IR drain ⫹ EUS cystgastrostomy.
2
42
No
Yes
2 of 2 stents
61
Infected pseudocyst. IR drain ⫹ EUS/ERP pancreaticoduodenostomy.
3
1
No
No
No
37
None
4
7
No
No
1 of 2 stents
36
None
5
21
No
No
No
36
None
6
46
No
No
No
22
None
7
1
No
No
No
15
None
8
2
No
Yes
No
14
None
9
1
No
No
No
10
None
10
2
No
No
No
6
Post-procedure fever. Antibiotics.
(Inside-Out) Endoscopic Ultrasound guided Fistula Puncture 11
73
No
No
No
25
None
12
1
No
Yes
No
16
None
13
10
No
Yes
1 of 1 stent
16
Infected pseudocyst. EUS cystgastrostomy
(Reconnecting the Disconnected Duct) IR guided Transpapillary Internalization 14
53
No
No
No
48
None
15
5
No
No
No
42
None
Median
7
25
PFC, Pancreatic fluid collection.
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