|
1
|
Singla V, Gupta PK, Singh P, Bopanna S, Shawl MR, Soni H, Goel A, Madan K, Garg P, Bhargava R. Novel treatment with double scope technique for disconnected pancreatic duct syndrome with external pancreatic fistula. Endosc Int Open 2024; 12:E593-E597. [PMID: 38654964 PMCID: PMC11039061 DOI: 10.1055/a-2290-0768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 03/12/2024] [Indexed: 04/26/2024] Open
Abstract
Background and study aims External pancreatic fistula in association with disconnected pancreatic duct syndrome is a common sequelae of the percutaneous step-up approach for infected pancreatic necrosis and is associated with significant morbidity. The present study aimed to report the initial outcome of a novel technique of two-scope guided tractogastrostomy for management of this condition. Patients and methods The present study was a retrospective analysis of data from patients with external pancreatic fistula and disconnected pancreatic duct syndrome, who underwent two-scope-guided tractogastrostomy. All the patients had a 24F or larger drain placed in the left retroperitoneum. Transgastric echo endoscopy and sinus tract endoscopy were performed simultaneously to place a stent between the gastric lumen and the sinus tract. Technical success was defined as placement of the stent between the tract and the stomach. Clinical success was defined as successful removal of the percutaneous drain without the occurrence of pancreatic fluid collection, ascites, external fistula, or another intervention 12 weeks after the procedure. Results Three patients underwent two scope-guided tractogastrostomy. Technical and clinical success were achieved in all the patients. No procedure-related side effects or recurrence occurred in any of the patients. Conclusions Two-scope-guided tractogastrostomy for treatment of external pancreatic fistula due to disconnected pancreatic duct syndrome is a feasible technique and can be further evaluated.
Collapse
Affiliation(s)
- Vikas Singla
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Pankaj Kumar Gupta
- Gastroeneterology, Max Super Speciality Hospital Saket, New Delhi, India
| | - Pankaj Singh
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Sawan Bopanna
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Muzaffer Rashid Shawl
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Harish Soni
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Akash Goel
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Kaushal Madan
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Pallavi Garg
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Richa Bhargava
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| |
Collapse
|
|
2
|
Cui Y, Kozarek RA. Evolution of Pancreatic Endotherapy. Gastrointest Endosc Clin N Am 2023; 33:679-700. [PMID: 37709404 DOI: 10.1016/j.giec.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
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.
Collapse
Affiliation(s)
- YongYan Cui
- Department of Gastroenterology, Virginia Mason Medical Center
| | | |
Collapse
|
|
3
|
Devière J. Endoscopic Ultrasound-Guided Pancreatic Duct Interventions. Gastrointest Endosc Clin N Am 2023; 33:845-854. [PMID: 37709415 DOI: 10.1016/j.giec.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Endoscopic ultrasound (EUS)-guided pancreatic duct drainage is one of the most challenging procedures in therapeutic endoscopy. Technical success is lower than for other therapeutic EUS procedures. However, when successful in a clear clinical indication, this procedure can offer a useful therapeutic alternative and improves the overall clinical success of the endoscopic approach. Current challenges include the standardization of clinical indications and of the techniques used for accessing the pancreatic duct, the strategy for mid-term and long-term management, and definition of the scope of the training that should be offered to a few highly experienced endoscopists.
Collapse
Affiliation(s)
- Jacques Devière
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, 808 Route de Lennik, Brussels B1070, Belgium.
| |
Collapse
|
|
4
|
Sundaram S, Patra BR, Choksi D, Giri S, Kale A, Ramani N, Karad A, Shukla A. Outcomes and predictors of response to endotherapy in pancreatic ductal disruptions with refractory internal and high-output external fistulae. Ann Hepatobiliary Pancreat Surg 2022; 26:347-354. [PMID: 35995583 PMCID: PMC9721253 DOI: 10.14701/ahbps.22-002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/08/2022] [Accepted: 03/17/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUNDS/AIMS Endoscopic retrograde cholangiopancreatography (ERCP) remains the primary treatment for a subset of patients with pancreatic fistulae. The objective of this study was reporting outcomes of ERCP and predictors of resolution in patients with pancreatic fistulae refractory to conservative therapy. METHODS Retrospective review of patients who underwent ERCP and pancreatic stent placement for pancreatic fistula not responding to medical therapy was performed. Clinical features, laboratory parameters, radiological features and pancreatogram findings were noted. Clinical resolution of fistula was the primary outcome measure. RESULTS Sixty-eight patients underwent ERCP for high-output pancreatic fistula (Mean age 34.1 years, 91.1% males, 35/68 chronic pancreatitis, 52.9% alcohol etiology). Internal fistulae (pancreatic ascites, pleural effusion, or pericardial effusion) were seen in 55 (80.9%) patients and external fistula in 13 (19.1%) patients. Technical success for ERCP was 92.6% (63/68). Leak was seen in 98.4% (62/63). The most common leak site was body (69.8%). Multiple leak sites were seen in 23.1%. Pancreatic stricture was found in 36.5%. In 44 (69.4%) patients, stent was placed beyond the site of the leak. Resolution at six weeks was achieved in 76.4% (52/68). On univariate and multivariate analyses, placement of stent beyond site of leak was significantly associated with resolution of high-output fistulae (3/41 [7.3%] vs. 5/19 [26.3%], p = 0.03; odds ratio: 6.5, 95% confidence interval: 1.211-34.94). CONCLUSIONS In our experience, ERCP was successful in 76% of patients with pancreatic fistulae refractory to conservative therapy. Stent placement beyond the site of leak was associated with higher resolution of fistulae.
Collapse
Affiliation(s)
- Sridhar Sundaram
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Biswa Ranjan Patra
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Dhaval Choksi
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Suprabhat Giri
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Aditya Kale
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Nitin Ramani
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Abhijeet Karad
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| | - Akash Shukla
- Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, India
| |
Collapse
|
|
5
|
Singla V, Arora A, Rana SS, Kohle M, Khare S, Kumar A, Bansal N, Sharma P. EUS-Guided Rendezvous and Tractogastrostomy: A Novel Technique for Disconnected Pancreatic Duct Syndrome with External Pancreatic Fistula. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1754334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Abstract
Background and Aims External pancreatic fistula occurring in the setting of disconnected pancreatic duct syndrome leads to significant morbidity, often requiring surgery. The aim of this study is to report a new technique of endoscopic ultrasound (EUS)-guided rendezvous and tractogastrostomy in patients with disconnected pancreatic duct syndrome and external pancreatic fistula.
Methods This study is retrospective analysis of the data of the patients with external pancreatic fistula who had undergone EUS-guided rendezvous and tractogastrostomy. Internalization of pancreatic secretions was performed by placing a stent between tract and the stomach. Technical success was defined as placement of stent between the tract and the stomach. Clinical success was defined as removal of external catheter and absence of peripancreatic fluid collection, ascites or external fistula at 3 months after the tractogastrostomy.
Results Four patients, all male, with median age of 33.5 years (range: 29–45), underwent EUS-guided tractogastrostomy. Technical and clinical success was 100%, without any procedure related complication. External catheter could be removed in all the patients. During the median follow-up of 10.5 months (range: 8–12), two patients had stent migration and peripancreatic fluid collection, which were managed by EUS-guided internal drainage.
Conclusions EUS-guided rendezvous and tractogastrostomy are a safe and effective technique for the treatment of external pancreatic fistula.
Collapse
Affiliation(s)
- Vikas Singla
- Center for Gastroenterology, Hepatology and Endoscopy, Max Superspeciality Hospital, Saket, New Delhi, India
| | - Anil Arora
- Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoj Kohle
- Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Shivam Khare
- Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Naresh Bansal
- Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Praveen Sharma
- Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| |
Collapse
|
|
6
|
Chen L, Li T, Wang B, Cheng Y, Zhao S, Lyu Y. Endoscopic versus percutaneous drainage for pancreatic fluid collection after pancreatic surgery: An up-to-date meta-analysis and systematic review. Asian J Surg 2022; 45:1519-1524. [PMID: 34642049 DOI: 10.1016/j.asjsur.2021.09.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/03/2021] [Accepted: 09/20/2021] [Indexed: 12/21/2022] Open
Abstract
Endoscopic ultrasound-guided drainage (EUSD) and percutaneous drainage (PD) have reportedly been used for postoperative pancreatic fluid collection (PFC). However, there is limited evidence regarding safety and efficacy in a comparison of EUSD and PD for postoperative PFC. We conducted a search of the databases PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov, to August 2020. Studies comparing EUSD and PD for postoperative PFC were included. The outcomes included technical success, clinical success, adverse events, and recurrence of PFC.We included a total of 6 studies involving 247 patients in the current study. There was no significant difference between EUSD and PD in terms of technical success (odds ratio [OR] = 0.95; 95% confidence interval [CI]: 0.29-3.12; p = 0.94) and clinical success (OR = 1.36; 95% CI: 0.68-2.72; p = 0.39). PFC recurrence and adverse events were similar between the two groups (OR = 1.82; 95% CI: 0.75-4.37; p = 0.18 and OR = 0.78; 95% CI: 0.31-1.92; p = 0.58, respectively).This meta-analysis confirmed that EUSD has comparable safety and efficacy to PD for postoperative PFC. Additional high-quality studies are required in the future.
Collapse
Affiliation(s)
- Liang Chen
- Department of Hepatobiliary Surgery, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China
| | - Ting Li
- Department of the Human, Wenzhou Medical University Affiliated Dongyang Hospital; Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China
| | - Bin Wang
- Department of Hepatobiliary Surgery, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China
| | - Yunxiao Cheng
- Department of Hepatobiliary Surgery, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China
| | - Sicong Zhao
- Department of Hepatobiliary Surgery, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China
| | - Yunxiao Lyu
- Department of Hepatobiliary Surgery, Wenzhou Medical University Affiliated Dongyang Hospital, Dongyang People's Hospital, Dongyang, Zhejiang, 322100, PR China.
| |
Collapse
|
|
7
|
Kuwatani M, Nagai K, Takishin Y, Furukawa R, Hirata H, Kawakubo K, Sakamoto N. Endoscopic ultrasonography-guided pancreaticoduodenostomy with a lumen-apposing metal stent to treat main pancreatic duct dilatation. Endoscopy 2022; 54:E113-E114. [PMID: 33784750 DOI: 10.1055/a-1408-0148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Masaki Kuwatani
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Kosuke Nagai
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Yunosuke Takishin
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Ryutaro Furukawa
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Hajime Hirata
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
| |
Collapse
|
|
8
|
Ramouz A, Shafiei S, Ali-Hasan-Al-Saegh S, Khajeh E, Rio-Tinto R, Fakour S, Brandl A, Goncalves G, Berchtold C, Büchler MW, Mehrabi A. Systematic review and meta-analysis of endoscopic ultrasound drainage for the management of fluid collections after pancreas surgery. Surg Endosc 2022; 36:3708-3720. [PMID: 35246738 PMCID: PMC9085703 DOI: 10.1007/s00464-022-09137-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/13/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The outcomes of endoscopic ultrasonography-guided drainage (EUSD) in treatment of pancreas fluid collection (PFC) after pancreas surgeries have not been evaluated systematically. The current systematic review and meta-analysis aim to evaluate the outcomes of EUSD in patients with PFC after pancreas surgery and compare it with percutaneous drainage (PCD). METHODS PubMed and Web of Science databases were searched for studies reporting outcomes EUSD in treatment of PFC after pancreas surgeries, from their inception until January 2022. Two meta-analyses were performed: (A) a systematic review and single-arm meta-analysis of EUSD (meta-analysis A) and (B) two-arm meta-analysis comparing the outcomes of EUSD and PCD (meta-analysis B). Pooled proportion of the outcomes in meta-analysis A as well as odds ratio (OR) and mean difference (MD) in meta-analysis B was calculated to determine the technical and clinical success rates, complications rate, hospital stay, and recurrence rate. ROBINS-I tool was used to assess the risk of bias. RESULTS The literature search retrieved 610 articles, 25 of which were eligible for inclusion. Included clinical studies comprised reports on 695 patients. Twenty-five studies (477 patients) were included in meta-analysis A and eight studies (356 patients) were included in meta-analysis B. In meta-analysis A, the technical and clinical success rates of EUSD were 94% and 87%, respectively, with post-procedural complications of 14% and recurrence rates of 9%. Meta-analysis B showed comparable technical and clinical success rates as well as complications rates between EUSD and PCD. EUSD showed significantly shorter duration of hospital stay compared to that of patients treated with PCD. CONCLUSION EUSD seems to be associated with high technical and clinical success rates, with low rates of procedure-related complications. Although EUSD leads to shorter hospital stay compared to PCD, the certainty of evidence was low in this regard.
Collapse
Affiliation(s)
- Ali Ramouz
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Saeed Shafiei
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Sadeq Ali-Hasan-Al-Saegh
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Ricardo Rio-Tinto
- Department of Gastroenterology, Digestive Oncology Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Sanam Fakour
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Andreas Brandl
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Gil Goncalves
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Champalimaud Foundation, Lisbon, Portugal
| | - Christoph Berchtold
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Markus W. Büchler
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| |
Collapse
|
|
9
|
Proença IM, dos Santos MEL, de Moura DTH, Ribeiro IB, Matuguma SE, Cheng S, McCarty TR, do Monte Junior ES, Sakai P, de Moura EGH. Role of pancreatography in the endoscopic management of encapsulated pancreatic collections - review and new proposed classification. World J Gastroenterol 2020; 26:7104-7117. [PMID: 33362371 PMCID: PMC7723666 DOI: 10.3748/wjg.v26.i45.7104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/08/2020] [Accepted: 11/21/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic fluids collections are local complications related to acute or chronic pancreatitis and may require intervention when symptomatic and/or complicated. Within the last decade, endoscopic management of these collections via endoscopic ultrasound-guided transmural drainage has become the gold standard treatment for encapsulated pancreatic collections with high clinical success and lower morbidity compared to traditional surgery and percutaneous drainage. Proper understanding of anatomic landmarks, including assessment of the main pancreatic duct and any associated lesions - such as disruptions and strictures - are key to achieving clinical success, reducing the need for reintervention or recurrence, especially in cases with suspected disconnected pancreatic duct syndrome. Additionally, proper review of imaging and anatomic landmarks, including collection location, are pivotal to determine type and size of pancreatic stenting as well as approach using long-term transmural indwelling plastic stents. Pancreatography to adequately assess the main pancreatic duct may be performed by two methods: Either non-invasively using magnetic resonance cholangiopancreatography or endoscopically via retrograde cholangiopan-creatography. Despite the critical need to understand anatomy via pancrea-tography and assess the main pancreatic duct, a standardized approach or uniform assessment strategy has not been described in the literature. Therefore, the aim of this review was to clarify the role of pancreatography in the endoscopic management of encapsulated pancreatic collections and to propose a new classification system to aid in proper assessment and endoscopic treatment.
Collapse
Affiliation(s)
- Igor Mendonça Proença
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Marcos Eduardo Lera dos Santos
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Sergio Eiji Matuguma
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Spencer Cheng
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Epifanio Silvino do Monte Junior
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | - Paulo Sakai
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas, University of São Paulo, São Paulo 05403000, Brazil
| | | |
Collapse
|
|
10
|
Kapoor H, Issa M, Winkler MA, Nair RT, Wesam F, Ganesh H. The augmented role of pancreatic imaging in the era of endoscopic necrosectomy: an illustrative and pictorial review. Abdom Radiol (NY) 2020; 45:1534-1549. [PMID: 31197462 DOI: 10.1007/s00261-019-02093-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic cystogastrostomy for mature pancreatic collections has long been recognized. However, FDA approval of newer lumen-apposing metallic stents in 2014 has now brought pancreatic necrosectomy to the endoscopic realm. Endoscopic drainage of Walled-off necrosis and direct endoscopic necrosectomy are technically challenging procedures with higher rates of complications. Collaborative clinical decision making both pre- and post-procedurally between the radiologist, endoscopist, and the surgeon can greatly improve outcomes in necrotizing pancreatitis. Herein, we review the basic pathophysiology that underlies progressive radiographic findings in NP, value of preprocedural imaging, current management algorithms, newer tools, and techniques as well as potential post-procedure complications on imaging follow-up after endoscopic interventions in necrotizing pancreatitis.
Collapse
|
|
11
|
Disconnected Pancreatic Duct Syndrome: Spectrum of Operative Management. J Surg Res 2019; 247:297-303. [PMID: 31685250 DOI: 10.1016/j.jss.2019.09.068] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 09/20/2019] [Accepted: 09/21/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Disconnected pancreatic duct syndrome (DPDS) is common after necrotizing pancreatitis (NP). Surgical management may be by internal drainage or left (distal) pancreatectomy. Therapeutic decision-making must consider sinistral portal hypertension, parenchymal volume of disconnected pancreas, and timing relative to definitive management of pancreatic necrosis. The aim of this study is to evaluate outcomes after operative management for DPDS. METHODS All patients with NP undergoing an operation for DPDS were included in the study (2005-2017). Perioperative outcomes and long-term durability were evaluated. RESULTS Among 647 patients with NP, 299 (46%) had DPDS. Operative management was required in 202/299 (68%) patients with DPDS. Median follow-up was 30 mo (2-165). Definitive operative therapy included internal drainage (n = 111) or resection (n = 91). Time from NP diagnosis to operation was 126 d (20 d to 81 mo). Overall morbidity was 46%. Postoperative length of stay was 7 d (2-97). Readmission was required in 39 patients (19%). Mortality was 2%. Repeat pancreatic intervention was required in 23 patients (11%) at a median of 15 mo (1-98). Repeat pancreatectomy was performed in nine patients and the remaining 14 patients were managed with endoscopic therapy. CONCLUSIONS DPDS is a common and challenging consequence of NP. Appropriate operation is durable in nearly 90% of patients.
Collapse
|
|
12
|
Endoscopic treatment of refractory external pancreatic fistulae with disconnected pancreatic duct syndrome. Pancreatology 2019; 19:608-613. [PMID: 31101469 DOI: 10.1016/j.pan.2019.05.454] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 04/23/2019] [Accepted: 05/10/2019] [Indexed: 12/11/2022]
Abstract
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.
Collapse
|
|
13
|
Jürgensen C, Hampe J. Reply. Gastrointest Endosc 2019; 89:1266. [PMID: 31104755 DOI: 10.1016/j.gie.2019.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/23/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Christian Jürgensen
- Department of Hepatology and Gastroenterology, Charité University, Berlin, Germany
| | - Jochen Hampe
- Medical Department 1, Technische Universität, Dresden, Germany
| |
Collapse
|
|
14
|
Arvanitakis M, Devière J. Postoperative pancreatic leaks and fistulas: beyond EUS-guided drainage of collections. Gastrointest Endosc 2019; 89:1265-1266. [PMID: 31104754 DOI: 10.1016/j.gie.2019.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/09/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Erasme University Hospital-Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Devière
- Department of Gastroenterology, Erasme University Hospital-Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
|
15
|
Caillol F, Godat S, Turrini O, Zemmour C, Bories E, Pesenti C, Ratone JP, Ewald J, Delpero JR, Giovannini M. Fluid collection after partial pancreatectomy: EUS drainage and long-term follow-up. Endosc Ultrasound 2019; 8:91-98. [PMID: 29600794 PMCID: PMC6482606 DOI: 10.4103/eus.eus_112_17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background and Objectives: Postoperative fluid collection due to pancreatic leak is the most frequent complication after pancreatic surgery. EUS-guided drainage of post-pancreatic surgery fluid collection is the gold standard procedure; however, data on outcomes of this procedure are limited. The primary endpoint of our study was relapse over longterm followup, and the secondary endpoint was the efficiency and safety of EUS-guided drainage of post-pancreatic surgery fluid collection. Patients and Methods: This retrospective study was conducted at a single center from December 2008 to April 2016. Global morbidity was defined as the occurrence of an event involving additional endoscopic procedures, hospitalization, or interventional radiologic or surgical procedures. EUS-guided drainage was considered a clinical failure if surgery was required to treat a relapse after stent removal. Results: Fortyone patients were included. The technical success rate was 100%. Drainage was considered a clinical success in 93% (39/41) of cases. Additionally, 19 (46%) complications were identified as global morbidity. The duration between surgery and EUS-guided drainage was not a significantly related factor for morbidity rate (P = 0.8); however, bleeding due to arterial injuries (splenic artery and gastroduodenal artery) from salvage drainage procedures occurred within 25 days following the initial surgery. There was no difference in survival between patients with and without complications. No relapse was reported during the followup (median: 44.75 months; range: 29.24 to 65.74 months). Conclusion: EUSguided drainage for post-pancreatic surgery fluid collection was efficient with no relapse during longterm followup. Morbidity rate was independent of the duration between the initial surgery and EUS-guided drainage; however, bleeding risk was likely more important in cases of early drainage.
Collapse
Affiliation(s)
- Fabrice Caillol
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Sebastien Godat
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | | | | | - Erwan Bories
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | | | | | - Jacques Ewald
- Surgery Unit, Paoli Calmettes Institute, Marseille, France
| | | | - Marc Giovannini
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| |
Collapse
|
|
16
|
Bang JY, Wilcox CM, Navaneethan U, Hasan MK, Peter S, Christein J, Hawes R, Varadarajulu S. Impact of Disconnected Pancreatic Duct Syndrome on the Endoscopic Management of Pancreatic Fluid Collections. Ann Surg 2018; 267:561-568. [PMID: 27849658 DOI: 10.1097/sla.0000000000002082] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To study the effect of disconnected pancreatic duct syndrome (DPDS) on endoscopic management of pancreatic fluid collections (PFCs). BACKGROUND Data on the impact of DPDS in patients undergoing endoscopic treatment of PFCs are limited. METHODS Retrospective study of patients undergoing endoscopic drainage of PFCs from 2003 to 2015. If treatment response was suboptimal following initial endoscopic or endoscopic ultrasound-guided transmural drainage, hybrid interventions (endoscopic ultrasound-guided multigate/dual modality technique, endoscopic/percutaneous sinus tract necrosectomy) were performed. Transmural stents were left permanently in situ in DPDS patients from 2008 onwards. Main outcome measures were to evaluate the effect of DPDS on need for hybrid treatment, reinterventions, rescue surgery, length of stay, and overall treatment success. RESULTS Of 361 patients, 34 (9.4%) were acute collections, 178 (49.3%) pseudocysts, and 149 (41.3%) walled-off necrosis (WON). DPDS was present in 167 (46.3%) patients, absent in 124 (34.3%), unknown in 70 (19.4%), and occurred more frequently in WON compared to other PFCs (68.3% vs 31.7%; P < 0.001). Although there was no difference in treatment success, more patients with DPDS required hybrid treatment (31.1% vs 4.8%, P < 0.001), reinterventions (30% vs 18.5%, P = 0.03), rescue-surgery (13.2% vs 4.8%, P = 0.02), and longer length of stay [median (interquartile range) days, 3 (2-10) vs 2 (1-4), P = 0.003]. PFC recurrence was lower in patients with DPDS with permanent transmural stents (17.4% vs 1.7%, P < 0.001). On multivariate logistic regression, DPDS [odds ratio (OR) 2.99], WON (OR 3.37), PFC size of 100 mm or more (OR 2.66), and multiple PFCs (OR 10.6) were associated with need for hybrid treatment. CONCLUSIONS DPDS has a significant effect on endoscopic management of PFCs as more patients required hybrid treatment, reinterventions, and rescue surgery for achieving optimal clinical outcomes.
Collapse
Affiliation(s)
- Ji Young Bang
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL
| | - Charles Melbern Wilcox
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Muhammad K Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL
| | - Shajan Peter
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL
| | - John Christein
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, FL
| | | |
Collapse
|
|
17
|
Cui B, Zhou L, Khan S, Cui J, Liu W. Role of enteral nutrition in pancreaticocolonic fistulas secondary to severe acute pancreatitis: A case report. Medicine (Baltimore) 2017; 96:e9054. [PMID: 29245311 PMCID: PMC5728926 DOI: 10.1097/md.0000000000009054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Pancreaticocolonic fistula (PCF) is an exceedingly rare complication of severe acute pancreatitis (SAP) and has primarily been treated surgically, but a few reported cases are successfully treated with nonsurgical methods. PATIENT CONCERNS A 32-year-old male presented to our hospital with chief complaints of sharp and persistent left upper quadrant abdominal pain radiating to the back. DIAGNOSES Computed tomography showed a pancreatic pseudocyst replacing a majority of the pancreatic parenchyma and PCF that formed between the pancreas and the colon. However, the final diagnosis of PCF was confirmed by drainage tube radiograph, which revealed extravasation of contrast from the tail of the pancreas into the colon. INTERVENTIONS A therapeutic strategy of enteral nutrition (EN) was applied. OUTCOMES The patient responded well to the treatment. No complication and recurrence were reported during 2-year follow-up. LESSONS This case highlights the role of EN in the treatment of PCF secondary to SAP. To the best of our knowledge, this is the first case of PCF that treated successfully with EN, rather than surgical or endoscopic intervention.
Collapse
Affiliation(s)
| | - Lu Zhou
- Department of Digestive Diseases
| | | | - Jianmin Cui
- Department of Imaging, General Hospital, Tianjin Medical University, Tianjin, China
| | | |
Collapse
|
|
18
|
Mutignani M, Dokas S, Tringali A, Forti E, Pugliese F, Cintolo M, Manta R, Dioscoridi L. Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification. Dig Dis Sci 2017; 62:2648-2657. [PMID: 28780610 DOI: 10.1007/s10620-017-4697-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/26/2017] [Indexed: 02/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Massimiliano Mutignani
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Stefanos Dokas
- Endoscopy Department, St Lukes Private Hospital, 55236, Panorama, Thessaloníki, Greece.
| | - Alberto Tringali
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Edoardo Forti
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Francesco Pugliese
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Marcello Cintolo
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| | - Raffaele Manta
- Digestive Endoscopy Unit, Nuovo Ospedale Civile S. Agostino Estense di Baggiovara, Via Pietro Giardini, 1355, 41126, Baggiovara, MO, Italy
| | - Lorenzo Dioscoridi
- Digestive and Interventional Endoscopy Unit, Ospedale Ca'Granda Niguarda, Piazza dell'Ospedale Maggiore, 3, 20162, Milan, Italy
| |
Collapse
|
|
19
|
Budzinsky SA, Shapoval'yants SG, Fedorov ED, Shabrin AV. [Endoscopic pancreatic stenting in pancreatic fistulas management]. Khirurgiia (Mosk) 2017:32-44. [PMID: 28303871 DOI: 10.17116/hirurgia2017232-44] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIM To present 18-year experience of endoscopic transpapillary stenting in patients with pancreatic fistula. MATERIAL AND METHODS The study included 48 patients with pancreatic fistula resistant to conservative management. Pancreatic stenting was successful in 32 (66.7%) patients. In 30 (93.8%) of them stenting appeared as the final stage of pancreatic fistula treatment. RESULTS Inclidence of complications after endoscopic treatment was 4.2%. We evaluated long-term results in 23 cases within 8-184 months. There were good results in 21 (91.3%) cases and satisfactory - in 2 (8.7%) cases. We had not unsatisfactory results in our experience.
Collapse
Affiliation(s)
- S A Budzinsky
- Scientific-educational center of abdominal surgery and endoscopy N.I. Pirogov RSMU; Municipal clinical hospital #31, Moscow, Russian Federation
| | - S G Shapoval'yants
- Scientific-educational center of abdominal surgery and endoscopy N.I. Pirogov RSMU; Municipal clinical hospital #31, Moscow, Russian Federation
| | - E D Fedorov
- Scientific-educational center of abdominal surgery and endoscopy N.I. Pirogov RSMU
| | - A V Shabrin
- Scientific-educational center of abdominal surgery and endoscopy N.I. Pirogov RSMU
| |
Collapse
|
|
20
|
Rodrigues-Pinto E, Baron TH. Endoscopic ultrasound-guided internalization of a pancreaticocutaneous fistula without need for percutaneous manipulation. Endosc Ultrasound 2016; 5:276-8. [PMID: 27503164 PMCID: PMC4989413 DOI: 10.4103/2303-9027.187895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Eduardo Rodrigues-Pinto
- Department of Gastroenterology, Centro Hospitalar São João, Porto, Portugal; Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA,
| | - Todd Huntley Baron
- Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| |
Collapse
|
|
21
|
Abstract
OPINION STATEMENT A disconnected pancreatic duct most commonly follows an episode of severe pancreatitis and walled-off necrosis (WON). When the latter is drained percutaneously, a pancreatic fistula connected to an upstream and disconnected duct is commonly seen. Transgastric drainage of WON with or without concomitant percutaneous drainage (dual drainage) will allow placement of two pigtail stents to drain the upstream duct and ultimately allows removal of percutaneous tubes and avoids the need for distal pancreatectomy. These stents should be left in place indefinitely. In patients referred with percutaneous drains and a disconnected pancreatic duct but without a concomitant fluid collection, a combined procedure, in which an interventional radiologist places a TIPS needle into the drain tract to puncture the stomach, allows the endoscopist access to dilate and stent the tract in a manner comparable to pseudocyst drainage. These stents should be left indefinitely, unless subsequent imaging demonstrates atrophy of the disconnected pancreatic tail.
Collapse
Affiliation(s)
- Michael Larsen
- Gastroenterology Division, Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA. .,Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA.
| | - Richard A Kozarek
- Gastroenterology Division, Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Avenue, C3-GAS, Seattle, WA, 98101, USA
| |
Collapse
|
|
22
|
Patel HG, Cavanagh Y, Shaikh SN. Pancreaticoureteral Fistula: A Rare Complication of Chronic Pancreatitis. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2016; 8:163-6. [PMID: 27114974 PMCID: PMC4821096 DOI: 10.4103/1947-2714.179134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Context: Chronic pancreatitis is an inflammatory condition that may result in progressive parenchymal damage and fibrosis which can ultimately lead to destruction of pancreatic tissue. Fistulas to the pleura, peritoneum, pericardium, and peripancreatic organs may form as a complications of pancreatitis. This case report describes an exceedingly rare complication, pancreaticoureteral fistula (PUF). Only two additional cases of PUF have been reported. However, they evolved following traumatic injury to the ureter or pancreatic duct. No published reports describe PUF as a complication of pancreatitis. Case Report: A 69-year-old Hispanic female with a past medical history of cholecystectomy, pancreatic pseudocyst, and recurrent episodes of pancreatitis presented with severe, sharp, and constant abdominal pain. Upon imaging, a fistulous tract was visualized between the left renal pelvis (at the level of an upper pole calyx) and the pancreatic duct and a ureteral stent was placed to facilitate fistula closure. Following the procedure, the patient attained symptomatic relief and oral intake was resumed. A left retrograde pyelogram was repeated 2 months after the initial stent placement and demonstrating no evidence of a persistent fistulous tract. Conclusion: Due to PUF's unclear etiology and possible variance of presentation, it is important for physicians to keep this rare complication of pancreatitis in mind, especially, when evaluating a patient with recurrent pancreatitis, urinary symptoms and abnormal imaging within the urinary collecting system and pancreas.
Collapse
Affiliation(s)
- Hiren G Patel
- Department of Medicine, Division of Gastroenterology, St. Joseph's Regional Medical Center, Paterson, New Jersey, USA
| | - Yana Cavanagh
- Department of Medicine, Trinitas Regional Medical Center, Elizabeth, New Jersey, USA; Department of Medicine, Seton Hall University School of Health and Medical Sciences, South Orange, New Jersey, USA
| | - Sohail N Shaikh
- Department of Medicine, Division of Gastroenterology, St. Joseph's Regional Medical Center, Paterson, New Jersey, USA
| |
Collapse
|
|
23
|
Lucatelli P, Sacconi B, Cereatti F, Argirò R, Corona M, Bezzi M, Fanelli F, Fiocca F, Saba L, Catalano C. Combined Endoscopic-Radiological Rendezvous for Distal Tail Postoperative Pancreatic Fistula (POPF). Cardiovasc Intervent Radiol 2016; 39:1327-31. [PMID: 27048486 DOI: 10.1007/s00270-016-1332-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 03/22/2016] [Indexed: 10/22/2022]
Abstract
Postoperative pancreatic fistula (POPF) with leakage of pancreatic juice is a rare, severe complication following pancreatic resection or, less commonly, splenectomy. Definitive treatment can require multidisciplinary approaches. We report a case of stenosis of the main pancreatic duct with distal tail GRADE C POPF, occurred after splenectomy for Hodgkin lymphoma, successfully treated with combined radiological-endoscopic approach.
Collapse
Affiliation(s)
- Pierleone Lucatelli
- Department of Radiological Sciences, Oncological and Anatomo-pathological Sciences, Vascular and Interventional Radiology Unit, "Sapienza" University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
| | - Beatrice Sacconi
- Department of Radiological Sciences, Oncological and Anatomo-pathological Sciences, Vascular and Interventional Radiology Unit, "Sapienza" University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.,Center for Life Nano Science@Sapienza, Istituto Italiano di Tecnologia, Viale Regina Elena 291, Rome, Italy
| | - Fabrizio Cereatti
- Department of General Surgery Paride Stefanini, Interventional Endoscopy Unit, "Sapienza" University of Rome, Rome, Italy
| | - Renato Argirò
- Department of Radiological Sciences, Oncological and Anatomo-pathological Sciences, Vascular and Interventional Radiology Unit, "Sapienza" University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Mario Corona
- Department of Radiological Sciences, Oncological and Anatomo-pathological Sciences, Vascular and Interventional Radiology Unit, "Sapienza" University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Mario Bezzi
- Department of Radiological Sciences, Oncological and Anatomo-pathological Sciences, Vascular and Interventional Radiology Unit, "Sapienza" University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Fabrizio Fanelli
- Department of Radiological Sciences, Oncological and Anatomo-pathological Sciences, Vascular and Interventional Radiology Unit, "Sapienza" University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Fausto Fiocca
- Department of General Surgery Paride Stefanini, Interventional Endoscopy Unit, "Sapienza" University of Rome, Rome, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria di Cagliari-Polo di Monserrato, Cagliari, Italy
| | - Carlo Catalano
- Department of Radiological Sciences, Oncological and Anatomo-pathological Sciences, Vascular and Interventional Radiology Unit, "Sapienza" University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| |
Collapse
|
|
24
|
Abstract
The major causes of benign biliary strictures include surgery, chronic pancreatitis, primary sclerosing cholangitis, and autoimmune cholangitis. Biliary leaks mainly occur after surgery and, rarely, abdominal trauma. These conditions may benefit from a nonsurgical approach in which endoscopic retrograde cholangiopancreatography (ERCP) plays a pivotal role in association with other minimally invasive approaches. This approach should be evaluated for any injury before deciding about the method for repair. ERCP, associated with peroral cholangioscopy, plays a growing role in characterizing undeterminate strictures, avoiding both unuseful major surgeries and palliative options that might compromise any further management.
Collapse
|
|
25
|
Endoscopic interventions for necrotizing pancreatitis. Am J Gastroenterol 2014; 109:969-81; quiz 982. [PMID: 24957157 DOI: 10.1038/ajg.2014.130] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 03/11/2014] [Indexed: 02/06/2023]
Abstract
Interventions for necrotizing pancreatitis have undergone a paradigm shift away from open surgical necrosectomy and toward minimally invasive techniques, with endoscopic transmural drainage (ETD) and necrosectomy emerging as principle forms of treatment. Recent multicenter studies, randomized trials, evidence-based guidelines, and consensus statements have endorsed the safety and efficacy of endoscopic and other minimally invasive techniques for the treatment of walled-off necrosis. A comprehensive review of indications, standard and novel approaches, outcomes, complications, and controversies regarding ETD and necrosectomy is presented. Given the inherent challenges and associated risks, endoscopic techniques for the management of necrotizing pancreatitis should be performed at specialized multidisciplinary centers by expert endoscopists well versed in the management of necrotizing pancreatitis.
Collapse
|
|
26
|
Varadarajulu S, Rana SS, Bhasin DK. Endoscopic therapy for pancreatic duct leaks and disruptions. Gastrointest Endosc Clin N Am 2013; 23:863-92. [PMID: 24079795 DOI: 10.1016/j.giec.2013.06.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, 601 East Rollins Street, Orlando, FL 32803, USA.
| | | | | |
Collapse
|
|
27
|
Bawany MZ, Rafiq E, Ahmad S, Chaudhry Q, Nawras A. Endoscopic therapy for significant gastric outlet obstruction caused by a small pancreatic pseudocyst with a unique shape and location. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2013; 2:196-198. [PMID: 23687609 DOI: 10.4161/jig.23746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 08/12/2012] [Accepted: 09/04/2012] [Indexed: 11/19/2022]
Abstract
Large perigastric or periduodenal pseudocysts are a potential cause of gastric outlet obstruction, usually requiring interventional drainage of the pseudocysts. In contrary most of the small pseudocysts are asymptomatic and require no therapy. However, certain small pseudocysts can produce clinically significant problem depending on their location. Here we report a case of small pseudocyst (12.0 mm in width) with a unique shape and location causing significant Gastric outlet obstruction treated successfully with endoscopy.
Collapse
Affiliation(s)
- Muhammad Z Bawany
- Department of Internal Medicine, University of Toledo Medical Center Toledo Ohio
| | | | | | | | | |
Collapse
|
|
28
|
Irani S, Gluck M, Ross A, Gan SI, Crane R, Brandabur JJ, Hauptmann E, Fotoohi M, Kozarek RA. Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video). Gastrointest Endosc 2012; 76:586-93.e933. [PMID: 22898416 DOI: 10.1016/j.gie.2012.05.006] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 05/04/2012] [Indexed: 02/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington 98111, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
|
29
|
Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic duct dilation after pancreatic surgery. Surg Endosc 2011; 26:1710-7. [PMID: 22179480 DOI: 10.1007/s00464-011-2097-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 11/26/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided drainage is widely used to manage pancreatic pseudocysts. Several studies have reported the use of EUS-guided drainage for pancreatic fistula and stasis of pancreatic juice caused by stricture of the pancreatic duct after pancreatic resection. METHODS At the authors' hospital, 262 patients underwent surgery involving pancreatic resection from April 2005 to March 2010. In 90 of these patients (34%), a grade B or C postoperative pancreatic fistula developed that required additional treatment. The authors performed EUS-guided transmural drainage (EUS-TD) for six patients (2.1%) with a pancreatic fistula or dilation of the main pancreatic duct visible by EUS. Percutaneous drainage was provided for 18 patients (6.8%). The success rates for EUS-TD and percutaneous drainage were compared in a retrospective analysis. RESULTS In all six cases, EUS-TD was performed successfully without complications. Five of the six patients were successfully treated with only one trial of EUS-TD. The final technical success rate was 100% for both EUS-TD and percutaneous drainage. Both the short- and long-term clinical success rates for EUS-TD were 100% and those for percutaneous drainage were 61.1 and 83%, respectively. The differences in these rates were not significant (short-term success, P = 0.091 vs. long-term success, P = 0.403). However, the time to clinical success was significantly shorter with EUS-TD (5.8 days) than with percutaneous drainage (30.4 days; P = 0.0013) in the current series. CONCLUSIONS The EUS-TD approach appears to be a safe and technically feasible alternative to percutaneous drainage and may be considered as first-line therapy for pancreatic fistulas visible by EUS.
Collapse
|
|
30
|
Nagatsu A, Taniguchi M, Shimamura T, Suzuki T, Yamashita K, Kawakami H, Abo D, Kamiyama T, Furukawa H, Todo S. Endoscopic naso-pancreatic drainage for the treatment of pancreatic fistula occurring after LDLT. World J Gastroenterol 2011; 17:3560-4. [PMID: 21941425 PMCID: PMC3163256 DOI: 10.3748/wjg.v17.i30.3560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 01/04/2011] [Accepted: 01/11/2011] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
|
31
|
Will U, Fueldner F, Goldmann B, Mueller AK, Wanzar I, Meyer F. Successful transgastric pancreaticography and endoscopic ultrasound-guided drainage of a disconnected pancreatic tail syndrome. Therap Adv Gastroenterol 2011; 4:213-8. [PMID: 21765865 PMCID: PMC3131165 DOI: 10.1177/1756283x10394232] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES We aim to demonstrate that endoscopic ultrasound (EUS)-guided transgastric pancreaticography/drainage of the pancreatic duct is feasible and successful in healing a persisting pancreaticocutaneous fistula. METHODS By means of a case report, we describe the following alternative therapeutic procedure. A 76-year-old male had: (1) 10 surgical interventions because of necrotizing acute pancreatitis with a persisting pancreaticocutaneous fistula (volume 200-300 ml/day); (2) an unsuccessful attempt of transpapillary drainage (disrupted duct after necrosectomy). He then underwent a EUS-guided transluminal pancreaticography/drainage of the pancreatic duct. A transgastric puncture was performed followed by, insertion of a guide wire into the dilated tail segment, and expansion of the gastropancreaticostomy using a 10-Fr retriever. A 10-Fr Amsterdam prosthesis was then placed through the guide wire. RESULTS The procedure was both a technical and clinical success as indicated by fistula occlusion and sufficient internal drainage of the pancreatic juice via the gastropancreaticostomy. No severe complications such as bleeding, perforation stent occlusion or migration were observed during the 15-month follow-up. CONCLUSIONS Transgastric pancreaticography and EUS-guided drainage of the enlarged pancreatic duct are elegant and feasible alternative options for the treatment of specific pancreatic lesions such as persisting pancreaticocutaneous fistula (complication after necrotizing pancreatitis), after pancreatic resective surgery, chronic pancreatitis and anomaly of the congenital pancreatic or postoperative gastrointestinal anatomy. Moreover, the procedure may represent a valid tool to avoid surgery and more invasive interventions.
Collapse
Affiliation(s)
| | | | | | | | - Igor Wanzar
- SRH Wald-Klinikum Gera gGmbH, Strasse des
Friedens 122, 07548 Gera, Germany
| | | |
Collapse
|
|
32
|
Abstract
Use of stents in the pancreas has been confined and limited to referral centers that specialize in the treatment of patients with severe pancreatitis and acute relapsing pancreatitis. With therapeutic development in endoscopic treatment of pancreatic diseases and a better understanding of the cause and prevention of ERCP related complications, the use of stents has been extended to transmural drainage of pancreatic fluid collection or of pancreatic ducts has well as to prophylaxis of post-ERCP pancreatitis. As a result, indication for pancreatic stenting and the kind of stents to be used as well as the followup after placement varies. This article reviews the major indication for pancreatic stent placement and focuses on the choice of stent, technique of implantation and followup.
Collapse
|
|
33
|
Kim YS, Hahm KB. Endotherapy of external pancreatic fistula: second-to-none choice for cure. J Gastroenterol Hepatol 2010; 25:1025-6. [PMID: 20594214 DOI: 10.1111/j.1440-1746.2010.06294.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
|
|
34
|
Bhasin DK, Rana SS, Rawal P. Endoscopic retrograde pancreatography in pancreatic trauma: need to break the mental barrier. J Gastroenterol Hepatol 2009; 24:720-8. [PMID: 19383077 DOI: 10.1111/j.1440-1746.2009.05809.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pancreatic injury has a high morbidity and mortality. The integrity of the main pancreatic duct is the most important determinant of prognosis. Serum amylase, peritoneal lavage and computed tomography of the abdomen can assist with diagnosis but endoscopic retrograde pancreatography (ERP) is the most accurate investigation for diagnosing the site and extent of ductal disruption. However, it is invasive and can be associated with significant complications. Magnetic resonance cholangiopancreatography (MRCP) and secretin-enhanced MRCP probably parallel ERP in delineating pancreatic ductal injuries. They can also delineate the duct upstream to complete disruption, an area not visualized on ERP. In relation to therapy, endoscopic transpapillary drainage has been successfully used to heal duct disruptions in the early phase of pancreatic trauma and, in the delayed phase, to treat the complications of pancreatic duct injuries such as pseudocysts and pancreatic fistulae. Transpapillary drainage is especially effective in patients who have partial pancreatic duct disruption that can be bridged. Endoscopic transmural drainage has also been successfully used to treat post-traumatic pancreatic pseudocysts. Further large, prospective and randomized studies are required to adjudge the efficacy and long-term safety of pancreatic duct drainage in the treatment of post-traumatic pancreatic duct injuries.
Collapse
Affiliation(s)
- Deepak K Bhasin
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
| | | | | |
Collapse
|
|
35
|
Devière J, Antaki F. Disconnected pancreatic tail syndrome: a plea for multidisciplinarity. Gastrointest Endosc 2008; 67:680-2. [PMID: 18374027 DOI: 10.1016/j.gie.2007.12.056] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 12/31/2007] [Indexed: 02/08/2023]
|
|
36
|
Abstract
How therapeutic endoscopy has changed! As participants and observers of the evolution of endotherapy, one has to marvel at the progress we have made in this field. We have withstood mild outrage of our description of precut sphincterotomy, to questions regarding the efficacy of balloon dilators for the bile and pancreatic duct sphincters, to outspoken objections at national meetings of our presentations describing the use of pancreatic stents for the treatment of various forms of pancreatitis, to the expectation of greater progress and advancement in the field. We routinely drain pseudocysts, stent disrupted pancreatic ducts, but, now, we commend the innovators from Erasme Hospital in Brussels for their newly described technique of completing an endoscopic rendezvous procedure performed through an external pancreatic fistula (EPF). In this new technique, an endoscopist, who is observing the progress of a percutaneous puncture through an EPF, positions an endoscope in the stomach or small bowel lumen while assisting another endoscopist (not a radiologist) who is advancing catheters and guide wires through the fistulous tract (a virtual cyst demonstrated by EUS) so that the assistant can guide the operator's puncture through the gut wall into the bowel lumen in order to deploy an internal stent to allow the normal flow or egress of pancreatic juices into the gut facilitating the closure of the fistula. Although the procedure is time-consuming and probably not cost-effective for the free enterprise reimbursement system in the United States, the results of this procedure, in a small number of patients over a long time period, were as effective as surgery. Our hats are off to those who continue to explore the outer limits of endotherapy, and we look forward to more exciting, unquestioned developments in the field. This is progress.
Collapse
|