Ann Hepatobiliary Pancreat Surg.  2022 Nov;26(4):347-354. 10.14701/ahbps.22-002.

Outcomes and predictors of response to endotherapy in pancreatic ductal disruptions with refractory internal and high-output external fistulae

• Sundaram S
• Patra BR
• Choksi D
• Giri S
• Kale A
• Ramani N
• Karad A
• Shukla A

• KMID: 2536385
• DOI: http://doi.org/10.14701/ahbps.22-002

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.

Keyword

Pancreatic fistula; Chronic pancreatitis; Acute pancreatitis; Endoscopic retrograde cholangiopancreatography

Figure

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  Fig. 1 Magnetic resonance cholangiopancreatography showing pancreatic leak (arrow) from the tail in a patient with ductal disruption and associated pseudocyst in the neck and proximal body of pancreas. CBD, common bile duct; PD, pancreatic duct; GB, gall bladder.

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  Fig. 2 (A) Native papilla in a patient with pancreatic pleural effusion and obstructive jaundice. (B) Pancreatogram showing leak in the tail of pancreas (arrow). (C) Pancreatic stent placement done to bridge the leak after sphincterotomy. (D) Stricture in distal common bile duct (CBD) on cholangiogram. (E) Plastic stent placement done in the distal CBD. (F) Fluoroscopic image showing stents in both CBD and pancreatic duct.

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  Fig. 3 Pancreatogram showing disruption in distal body of pancreas (arrow) having a percutaneous drain in peripancreatic collection, with wire passing into the collection.

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  Fig. 4 Pancreatogram showing stricture in region of head (white arrow) with leak from tail of pancreas (black arrow).

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  Fig. 5 Flow diagram of study outcomes. PD, pancreatic duct; ERCP, endoscopic retrograde cholangiopancreatography.

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