Clin Endosc.  2024 Nov;57(6):735-746. 10.5946/ce.2023.254.

Drainage for fluid collections post pancreatic surgery and acute pancreatitis: similar but different?

• Nakai Y
• Matsubara S
• Mukai T
• Hamada T
• Sasaki T
• Ishiwatari H
• Hijioka S
• Shiomi H
• Takenaka M
• Iwashita T
• Masuda A
• Saito T
• Isayama H
• Yasuda I
• for the WONDERFUL study group in Japan

• KMID: 2561155
• DOI: http://doi.org/10.5946/ce.2023.254

Abstract

Postoperative pancreatic fistulas (POPFs) are common adverse events that occur after pancreatic surgery. Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) is a first-line treatment, similar to that for pancreatic fluid collection (PFCs) after acute pancreatitis. However, some POPFs do not develop fluid collections depending on the presence or location of the surgical drain, whereas others develop fluid collections, such as postoperative fluid collections (POPFCs). Although POPFCs are similar to PFCs, the strategy and modality for POPF management need to be modified according to the presence of fluid collections, surgical drains, and surgical type. As discussed for PFCs, the indications, timing, and selection of interventions or stents for EUS-D have not been fully elucidated for POPFs. In this review, we discuss the management of POPFs and POPFCs in comparison with PFCs due to acute pancreatitis and summarize the topics that should be addressed in future studies.

Keyword

Drainage; Endosonography; Pancreatic fistula; Postoperative complications

Figure

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  Fig. 1. Grading of postoperative pancreatic fistula by International Study Group on Pancreatic Surgery. POPF, postoperative pancreatic fistula.

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  Fig. 2. Endoscopic ultrasonography (EUS)-guided drainage of postoperative pancreatic fluid collection (POPFC) after distal pancreatectomy. (A) Bilocular POPFC seen on computed tomography (CT). (B) Communication of bilocular POPFC on CT. (C) EUS image of POPFC at surgical resection margin. (D) EUS image of POPFC at the tail side with some debris. (E) Two guidewires were advanced into both components of POPFCs. (F) Two double pigtail plastic stents and one nasocystic drainage tube were placed.

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  Fig. 3. Endoscopic ultrasonography (EUS)-assisted rendezvous for postoperative pancreatic fistula without fluid collection after distal pancreatectomy with pancreatic divisum. (A) A limited fluid collection around the surgical site seen on computed tomography (CT). (B) Surgical drain left in place on CT. (C) After failed minor papilla cannulation, the pancreatic duct was punctured under EUS-guidance for rendezvous technique. (D) Successful minor papilla cannulation by EUS-assisted rendezvous. (E) A pancreatic stent was placed. (F) Endoscopic image of a pancreatic stent through the minor papilla.

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  Fig. 4. A proposal for strategy of postoperative pancreatic fistula. BE-ERCP, balloon endoscope-assisted endoscopic retrograde cholangiopancreatography; DP, distal pancreatectomy; ERCP, endoscopic retrograde cholangiopancreatography; EUS-D, endoscopic ultrasonography-guided drainage; EUS-PDD, EUS-guided pancreatic duct drainage; EUS-RV, EUS-assisted rendezvous; MPD, main pancreatic duct; PD, pancreaticoduodenectomy; POPF, postoperative pancreatic fistula. a)EUS-guided drainage of artificially created fluid collection or direct fistula tract drainage. b)EUS-guided rendezvous via the percutaneous route. c)EUS-guided rendezvous with ERCP or BE-ERCP.

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