Annals of Hepato-Biliary-Pancreatic Surgery (한국간담췌외과학회지)

The Korean Association of Hepato-Biliary-Pancreatic Surgery (한국간담췌외과학회)
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Outcomes and predictors of response to endotherapy in pancreatic ductal disruptions with refractory internal and high-output external fistulae

  • Sridhar Sundaram (Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College) ;
  • Biswa Ranjan Patra (Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College) ;
  • Dhaval Choksi (Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College) ;
  • Suprabhat Giri (Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College) ;
  • Aditya Kale (Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College) ;
  • Nitin Ramani (Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College) ;
  • Abhijeet Karad (Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College) ;
  • Akash Shukla (Department of Gastroenterology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College)
  • Received : 2022.01.13
  • Accepted : 2022.03.17
  • Published : 2022.11.30
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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.

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References

  1. Morgan KA, Adams DB. Management of internal and external pancreatic fistulas. Surg Clin North Am 2007;87:1503-1513, x.  https://doi.org/10.1016/j.suc.2007.08.008
  2. Larsen M, Kozarek R. Management of pancreatic ductal leaks and fistulae. J Gastroenterol Hepatol 2014;29:1360-1370.  https://doi.org/10.1111/jgh.12574
  3. Adams DB, Srinivasan A. Failure of percutaneous catheter drainage of pancreatic pseudocyst. Am Surg 2000;66:256-261.  https://doi.org/10.1177/000313480006600306
  4. Saadia R. Fistulas of the pancreas. In: Holzheimer RG, Mannick JA, eds. Surgical treatment: evidence-based and problem-oriented. Munich: Zuckschwerdt, 2001. 
  5. Mutignani M, Dokas S, Tringali A, Forti E, Pugliese F, Cintolo M, et al. Pancreatic leaks and fistulae: an endoscopy-oriented classification. Dig Dis Sci 2017;62:2648-2657.  https://doi.org/10.1007/s10620-017-4697-5
  6. Varadarajulu S, Rana SS, Bhasin DK. Endoscopic therapy for pancreatic duct leaks and disruptions. Gastrointest Endosc Clin N Am 2013;23:863-892.  https://doi.org/10.1016/j.giec.2013.06.008
  7. Rana SS, Sharma R, Kang M, Gupta R. Natural course of low output external pancreatic fistula in patients with disconnected pancreatic duct syndrome following acute necrotising pancreatitis. Pancreatology 2020;20:177-181.  https://doi.org/10.1016/j.pan.2019.12.011
  8. O'Toole D, Vullierme MP, Ponsot P, Maire F, Calmels V, Hentic O, et al. Diagnosis and management of pancreatic fistulae resulting in pancreatic ascites or pleural effusions in the era of helical CT and magnetic resonance imaging. Gastroenterol Clin Biol 2007;31(8-9 Pt 1):686-693.  https://doi.org/10.1016/S0399-8320(07)91918-1
  9. Akisik MF, Sandrasegaran K, Aisen AA, Maglinte DD, Sherman S, Lehman GA. Dynamic secretin-enhanced MR cholangiopancreatography. Radiographics 2006;26:665-677.  https://doi.org/10.1148/rg.263055077
  10. Arvanitakis M, Delhaye M, Bali MA, Matos C, Le Moine O, Deviere J. Endoscopic treatment of external pancreatic fistulas: when draining the main pancreatic duct is not enough. Am J Gastroenterol 2007;102:516-524. Erratum in: Am J Gastroenterol 2007;102:1141. 
  11. Gans SL, van Westreenen HL, Kiewiet JJ, Rauws EA, Gouma DJ, Boermeester MA. Systematic review and meta-analysis of somatostatin analogues for the treatment of pancreatic fistula. Br J Surg 2012;99:754-760.  https://doi.org/10.1002/bjs.8709
  12. Hesse U, Ysebaert D, de Hemptinne B. Role of somatostatin-14 and its analogues in the management of gastrointestinal fistulae: clinical data. Gut 2001;49(Suppl 4):iv11-iv21.  https://doi.org/10.1136/gut.49.suppl_4.iv11
  13. Han X, Xu Z, Cao S, Zhao Y, Wu W. The effect of somatostatin analogues on postoperative outcomes following pancreatic surgery: a meta-analysis. PLoS One 2017;12:e0188928. 
  14. Zheng H, Qin J, Wang N, Chen W, Huang Q. An updated systematic review and meta-analysis of the use of octreotide for the prevention of postoperative complications after pancreatic resection. Medicine (Baltimore) 2019;98:e17196. 
  15. Baron TH. Endoscopic drainage of pancreatic fluid collections and pancreatic necrosis. Gastrointest Endosc Clin N Am 2003;13:743-764.  https://doi.org/10.1016/S1052-5157(03)00100-4
  16. Abdallah AA, Krige JE, Bornman PC. Biliary tract obstruction in chronic pancreatitis. HPB (Oxford) 2007;9:421-428.  https://doi.org/10.1080/13651820701774883
  17. Das R, Papachristou GI, Slivka A, Easler JJ, Chennat J, Malin J, et al. Endotherapy is effective for pancreatic ductal disruption: a dual center experience. Pancreatology 2016;16:278-283.  https://doi.org/10.1016/j.pan.2015.12.176
  18. Gupta S, Gaikwad N, Samarth A, Sawalakhe N, Sankalecha T. Efficacy of pancreatic endotherapy in pancreatic ascites and pleural effusion. Med Sci (Basel) 2017;5:6. 
  19. Telford JJ, Farrell JJ, Saltzman JR, Shields SJ, Banks PA, Lichtenstein DR, et al. Pancreatic stent placement for duct disruption. Gastrointest Endosc 2002;56:18-24.  https://doi.org/10.1067/mge.2002.125107
  20. Varadarajulu S, Noone TC, Tutuian R, Hawes RH, Cotton PB. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc 2005;61:568-575.  https://doi.org/10.1016/S0016-5107(04)02832-9
  21. Bakker OJ, van Baal MC, van Santvoort HC, Besselink MG, Poley JW, Heisterkamp J, et al. Endoscopic transpapillary stenting or conservative treatment for pancreatic fistulas in necrotizing pancreatitis: multicenter series and literature review. Ann Surg 2011;253:961-967.  https://doi.org/10.1097/SLA.0b013e318212e901
  22. Tilara A, Gerdes H, Allen P, Jarnagin W, Kingham P, Fong Y, et al. Endoscopic ultrasound-guided transmural drainage of postoperative pancreatic collections. J Am Coll Surg 2014;218:33-40.  https://doi.org/10.1016/j.jamcollsurg.2013.09.001
  23. Jurgensen C, Distler M, Arlt A, Bruckner S, Ellrichmann M, Matthes K, et al. EUS-guided drainage in the management of postoperative pancreatic leaks and fistulas (with video). Gastrointest Endosc 2019;89:311-319.e1.  https://doi.org/10.1016/j.gie.2018.08.046
  24. Fujimori N, Osoegawa T, Aso A, Itaba S, Minoda Y, Murakami M, et al. Efficacy of early endoscopic ultrasound-guided transluminal drainage for postoperative pancreatic fistula. Can J Gastroenterol Hepatol 2021;2021:6691705. 
  25. Kawaguchi Y, Lin JC, Kawashima Y, Maruno A, Ito H, Ogawa M, et al. Risk factors for migration, fracture, and dislocation of pancreatic stents. Gastroenterol Res Pract 2015;2015:365457.