Strategy to Treat Pancreatic Fistula Using Comprehensive Endoscopic Procedures Together with Percutaneous Methods

Abstract

Objective: Pancreatic fistula (PF) is an early complication after pancreatoduodenectomy. PF occurs because of disruption to the pancreatodigestive tract anastomosis with stricture or occlusion. A strategy to treat PF using interventional methods is proposed. Methods: We treated a total of 6 patients with PF by endoscopic ultrasound (EUS)-guided or percutaneous pancreatic duct drainage. In this paper, these patients are reviewed based on the applied treatment for PF. Results: At the time of introduction to our department, all the patients, except for one, had a percutaneous drainage tube implanted prior to surgery. In 2 patients undergoing pancreatojejunostomy within 3 months of the previous surgery, percutaneous introduction of a guidewire into the anastomosed jejunum, via the disrupted anastomosis, through the percutaneous fistula and the implantation of a percutaneous jejunal tube for 6 weeks was an effective PF treatment. There were 4 patients (3 pancreatojejunostomy, 1 pancreatogastrostomy) with more than 3 months of PF, with an occluded anastomosis and the pancreatic juice flow had to be rerouted by making another pancreatodigestive tract anastomosis using percutaneous or EUS-guided puncture of the pancreatic duct. Conclusions: The optimal treatment for PF is considered to be the recanalization of the stricture or occluded anastomosis, or rerouting of the pancreatic juice flow by making another anastomosis. Considering our experiences in the treatment of PF, EUS-guided puncture of the pancreatic duct near the occluded anastomosis using a convex-type EUS endoscopy is the most preferable method to treat PF. In patients for whom it is difficult to introduce the endoscope into the afferent loop in the pancreatojejunostomy, various methods, including percutaneous approaches, are feasible to treat PF.