Endoscopic treatment of pancreatic fistulas

A Step-Up Approach Using Alternative Endoscopic Modalities Is an Effective Strategy for Postoperative and Traumatic Pancreatic Duct Disruption

BACKGROUND AND AIMS

Standard endotherapy for pancreatic duct (PD) disruption is pancreatic stenting and sphincterotomy. In patients refractory to standard treatment, treatment algorithm is currently not standardized. This study aims to report the 10-year experience with the endoscopic treatment of postoperative or traumatic PD disruption and to share our algorithmic approach.

METHODS

This retrospective study was conducted on 30 consecutive patients who underwent endoscopic treatment for postoperative (n = 26) or traumatic (n = 4) PD disruption between 2011 and 2021. Standard treatment was initially applied to all patients. Endoscopic modalities used with a step-up approach in patients unresponsive to standard treatment were stent upsizing and N-butyl-2-cyanoacrilate (NBCA) injection for partial disruption, and the bridging of the disruption with a stent and cystogastrostomy for complete disruption.

RESULTS

PD disruption was partial in 26 and complete in 4 patients. Cannulation and stenting of PD was successful in all patients and sphincterotomy was performed in 22 patients. Standard treatment was successful in 20 patients (66.6%). The resolution of PD disruption in 9 of 10 patients refractory to standard treatment was achieved with stent upsizing in 4, NBCA injection in 2, the bridging of the complete disruption in one, and cystogastrostomy after spontaneously and intentionally developed pseudocyst in one patient each. Overall, therapeutic success rate was 96.6% (100% for partial, 75% for complete disruption). Procedural complications occurred in 7 patients.

CONCLUSIONS

Standart treatment for PD disruption is usually effective. In patients refractory to standard treatment, the outcome may be improved by step-up approach using alternative endoscopic modalities.

[Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]

Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.

Endoscopic treatment of refractory external pancreatic fistulae with disconnected pancreatic duct syndrome

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.

Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification

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.

Dual drainage using a percutaneous pancreatic duct technique contributed to resolution of severe acute pancreatitis

A 66-year-old man was admitted for severe acute alcoholic pancreatitis with infected pancreatic necrosis (IPN). Abdominal computed tomography revealed an inflamed pancreatic head, a dilated main pancreatic duct (MPD), and a large cavity with heterogeneous fluid containing gas adjacent to the pancreatic head, and extending to the pelvis. The cavity was drained percutaneously near the pancreatic head on admission; another tube was inserted into the pelvic cavity on hospital day 3. The drained fluid contained pus with high amylase concentration. Nasopancreatic drainage tube placement was unsuccessfully attempted on hospital day 9. On hospital day 23, percutaneous puncture of the MPD and placement of a pancreatic duct drainage tube was performed. Pancreatography revealed major extravasation from the pancreatic head. The IPN cavity receded; the percutaneous IPN drainage tube was removed on hospital day 58. On hospital day 83, the pancreatic drainage was changed to a transpapillary pancreatic stent, and the patient was discharged. Measuring the amylase concentration of peripancreatic fluid collections can aid in the diagnosis of pancreatic duct disruption; moreover, dual percutaneous necrotic cavity drainage plus pancreatic duct drainage may be essential for treating IPN. If transpapillary drainage tube placement is difficult, percutaneous pancreatic duct drainage may be feasible.

Early dual drainage combining transpapillary endotherapy and percutaneous catheter drainage in patients with pancreatic fistula associated with severe acute pancreatitis

BACKGROUND

The development of pancreatic fistula (PF) associated with pancreatic necrosis is of great concern in the management of severe acute pancreatitis (SAP). We expected that early recognition and intervention of PF combined with percutaneous catheter drainage (PCD) for pancreatic infection may improve SAP outcomes.

METHODS

Fifteen consecutive patients with SAP were enrolled. Whenever feasible, fine-needle aspiration for fluid collection was performed to determine infection and amylase concentration. For infection and PF with amylase-rich fluid, PCD and transpapillary endotherapy (preferably naso-pancreatic drainage) were carried out as soon as possible. PCD was intensively managed by irrigating the sized-up and multiple large bore catheters.

RESULTS

Infected fluid collection and PF were both detected in 13 (86.7%) patients. Pancreatic duct (PD) disruption (n = 6) and organ failure (n = 5) occurred exclusively in patients with amylase-rich collection ≥10,000 U/L. The median timing of PCD and endotherapy was 15.5 and 16.5 days, respectively. No serious complications or mortality resulted from intervention procedures other than stent occlusion in one (6.7%) patient. Surgical intervention due to uncontrollable infection and visceral organ injury was avoided. Fistula closure was achieved in 12 (92.3%) of 13 PF patients with a median duration of 45 days. Disease-related mortality occurred in one (6.7%) patient.

CONCLUSION

Amylase-rich fluid collection ≥10,000 U/L may be an indication for further endoscopic investigation of PD disruption. Early dual drainage combining pancreatic endotherapy and PCD is feasible and safe, and may improve treatment outcome.

Endoscopic transpapillary stenting for pancreatic fistulas after necrosectomy with necrotizing pancreatitis

BACKGROUND

Data concerning the incidence and treatment of pancreatic fistula after necrosectomy in severe acute necrotizing pancreatitis (SAP) are scarce. Our aim was to assess the incidence of pancreatic fistula, and the feasibility and results of endoscopic transpapillary stenting (ETS) in patients with SAP after necrosectomy.

METHODS

From January 2009 to December 2012 twenty-nine consecutive patients with SAP and necrosectomy in Oulu University Hospital were enrolled into this study. Five patients died before ETS because of the rapid progress of the disease and were, therefore, excluded.

RESULTS

ERP was performed for the remaining 24 patients demonstrating fistula in 22/24 patients (92 %). ETS was successful in 23 patients and the fistula closed in all of them after a median of 82 (2-210) days with acceptable morbidity and no procedure-related mortality.

CONCLUSION

All patients after necrosectomy for SAP seem to have internal or external pancreatic fistula. EST aimed at internal drainage of the necrosectomy cavity is a feasible and effective therapy in these patients.

Alcoholic severe acute pancreatitis with positive culture of pancreatic juice treated by nasopancreatic drainage

BACKGROUND

Severe acute pancreatitis (SAP) is a serious disease associated with alcoholism and has a high mortality rate. Effective treatments have not been established.

METHODS

A 58-year-old man was admitted due to alcoholic SAP. Endoscopic retrograde cholangiopancreatography revealed pancreatic calculi at the pancreas head and a stricture in the pancreatic duct from the pancreas head to the body. Endoscopically, nasopancreatic drainage (NPD) was placed through the minor papilla to the pancreas tail beyond the stricture.

RESULTS

Pancreatic juice culture was positive for Streptococcus and Enterobacter. The day after NPD, upper abdominal pain was relieved. After changing NPD to a pancreatic stent, the patient was discharged on day 21 post-NPD.

CONCLUSION

Alcoholic SAP may reflect aggravation of chronic pancreatitis. The possibility of acute bacterial inflammation should be considered in all cases of chronic alcoholic pancreatitis who present with severe features of inflammation, even in the early stages of an attack. Treatment of this subset of cases by drainage could be of great importance and NPD may be the preferred method.

Endoscopic therapy for pancreatic duct leaks and disruptions

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.

Pancreatic and biliary stents

Biliary and pancreatic stents are used in a variety of benign and malignant conditions including strictures and leaks and in the prevention of post-ERCP pancreatitis.Both plastic and metal stents are safe, effective, and easy to use. SEMSs have traditionally been used for inoperable malignant disease. Covered SEMSs are now being evaluated for use in benign disease. Increasing the duration of patency of both plastic and metal stents remains an important area for future research.

Pancreatic fistula: A proposed percutaneous procedure

AIM

To propose a percutaneous treatment for otherwise intractable pancreatic fistula (PF).

METHODS

From 2005 to 2011, 12 patients (9 men and 3 women, mean age 59 years, median 63 years, range 33-78 years) underwent radiological treatment for high-output PF associated with peripancreatic fluid collection. The percutaneous procedures were performed after at least 4 wk of unsuccessful conservative treatments. We chose either a one or two step procedure, depending on the size and characteristics of the fistula and the fluid collection (with an arbitrary cut-off of 2 cm). Initially, 2 to 6 pigtail drainages of variable size from 8.3 (8.3-Pig Duan Cook, Bloomington, Indiana, United States) to 14 Fr (Flexima, Boston Scientific, Natick, United States) were positioned inside the collection using a transgastric approach. In a second procedure, after 7-10 d, two or more endoprostheses (cystogastrostomic 8 Fr double-pigtail, Cook, Bloomington, Indiana, United States in 10 patients; covered Niti-S stent, TaeWoong Medical Co, Seoul, South Korea in 2 patients) were placed between the collection and the gastric lumen. In all cases the metal or plastic prostheses were removed within one year after positioning.

RESULTS

Four out of 12 high-output fistulas fistulas were external while 8/12 were internal. The origin of the fistulous tract was visualised by computer tomography (CT) imaging studies: in 11 patients it was at the body, and in 1 patient at the tail of the pancreas. Single or multiple drainages were positioned under CT guidance. The catheters were left in place for a varying period (0 to 40 d - median 10 and 25(th)-75(th) percentile 0-14). In one case external transgastric drainages were left in place for a prolonged time (40 d) due to the presence of vancomycin-resistant bacteria (Staphylococcus) and fluconazole-resistant fungi (Candida) in the drained fluid. In this latter case systemic and local antibiotic therapy was administered. In both single and two-step techniques, when infection was present, we carried out additional washing with antibiotics to improve the likelihood of the procedure's success. In all cases the endoprostheses were left in situ for a few weeks and endoscopically removed after remission of collections, as ascertained by CT scan. Procedural success rate was 100% as the resolution of external PF was achieved in all cases. There were no peri-procedural complications in any of the patients. The minimum follow-up was 18 mo. In two cases the procedure was repeated after 1 year, due to the onset of new fluid collections and the development of pseudocysts. Indeed, this type of endoprosthesis is routinely employed for the treatment of pseudocysts. Endoscopy was adopted both for control of the positioning of the endoprosthesis in the stomach, and for its removal after resolution of the fistula and fluid collection. The resolution of the external fistula was assessed clinically and CT scan was employed to demonstrate the resolution of peripancreatic collections for both the internal and external fistulae.

CONCLUSION

The percutaneous placement of cistogastrostomic endoprostheses can be used for the treatment of PF that cannot be treated with other procedures.

Systematic review and meta-analysis of somatostatin analogues for the treatment of pancreatic fistula

BACKGROUND

Somatostatin analogues are used for the treatment of pancreatic fistula, with the aim of achieving fistula closure or reduction of output.

METHOD

MEDLINE, Embase and Cochrane databases were searched systematically for relevant articles followed by hand-searching of reference lists. Data on patient recruitment, intervention and outcome were extracted and meta-analysis performed where reasonable.

RESULTS

Seven randomized clinical trials met the inclusion criteria and included a total of 297 patients with fistulas of the gastrointestinal tract; of these, 102 patients had fistulas of pancreatic origin. Pooling of closure rates showed no significant difference between patients treated with somatostatin analogues compared with controls: odds ratio 1·52 (95 per cent confidence interval 0·88 to 2·61). Owing to inconsistent descriptions, pooling of results was not possible for other endpoints, such as time to fistula closure.

CONCLUSION

There is no solid evidence that somatostatin analogues result in a higher closure rate of pancreatic fistula compared with other treatments.

Chronic pancreatitis and exocrine insufficiency

The evaluation, management, and follow-up of patients with chronic pancreatitis (CP) can be simple, but it can also be complex, so having a good referral network of subspecialists experienced in this field is essential. Identifying the cause of CP requires a systematic review of the many potential causes when the cause is not obvious. The identification of patients with autoimmune CP is particularly important because treatment with steroids may be effective. Alterations in pain or other symptoms in patients with CP should not be attributed to worsening disease before evaluations for complications including malignancy are done.

Interventional radiology in the management of abdominal collections after distal pancreatectomy: a retrospective review

OBJECTIVE

The purpose of this study was to assess the technical and clinical success and complications of imaging-guided percutaneous catheter drainage of peripancreatic fluid collections after distal pancreatectomy.

MATERIALS AND METHODS

Between January 2001 and February 2009, the cases of patients who underwent distal pancreatectomy were selected from a surgical database, and the cases of those who underwent subsequent interventional radiologic percutaneous drainage were identified. Details of percutaneous catheter drainage were recorded, and technical and clinical success was determined. Technical success was defined as successful percutaneous imaging-guided placement of a drainage catheter. Primary clinical success was defined as resolution of peripancreatic fluid collection with percutaneous drainage only. Secondary clinical success was defined as resolution of peripancreatic fluid collection with percutaneous drainage and additional manipulations (i.e., tube repositioning, additional catheter drainage) and no surgical débridement. Multifactor logistic regression analysis was used to identify predictors of drain failure.

RESULTS

Between January 2001 and February 2009, 365 patients underwent distal pancreatectomy. Of these, 51 patients (14%; 25 men, 26 women; mean age, 53.4 years; range, 18-81 years) underwent 57 CT-guided percutaneous procedures for drainage of postsurgical peripancreatic fluid collection. The mean interval between surgery and drainage was 23.5 days (median, 17 days; range, 2-120 days), and the mean collection size was 7.3 cm in transverse dimension (median, 6.9 cm; range, 2.3-16 cm). The mean duration of catheter drainage was 39.7 days (median, 24 days; range, 3-220 days). The technical success rate was 100%, primary clinical success rate was 60%, and primary and secondary clinical success rates together were 95%. Three of the 51 patients (6%) needed surgery for definitive management of the collection. One of 51 patients (2%) had a complication of the interventional radiologic procedure. Catheter size and the need for additional catheter manipulation were significantly associated with drainage failure (p < 0.05).

CONCLUSION

Catheter drainage of peripancreatic fluid collections after distal pancreatectomy is a technically safe and clinically effective procedure. Although extra manipulations may be needed to achieve clinical success, the combined primary and secondary clinical success rates are high.

Role of diaphragm in pancreaticopleural fistula

A pancreatic pleural effusion may result from a pancreatopleural fistula. We herein discuss two interesting issues in a similar case report of a pleural effusion caused after splenectomy, which was recently published in the World Journal of Gastroenterology. Pancreatic exudate passes directly through a natural hiatus in the diaphragm or by direct penetration through the dome of the diaphragm from a neighboring subdiaphragmatic collection. The diaphragmatic lymphatic “stomata” does not contribute to the formation of such a pleural effusion, as it is inaccurately mentioned in that report. A strictly conservative approach is recommended in that article as the management of choice. Although this may be an option in selected frail patients, there has been enough accumulative evidence that a pancreaticopleural fistula may be best managed by early endoscopy in order to avoid complications causing prolonged hospitalization.

Endoscopic transpapillary drainage for external fistulas developing after surgical or radiological pancreatic interventions

BACKGROUND AND AIMS

External pancreatic fistulas (EPFs) are a therapeutic challenge. The present study was conducted to evaluate the efficacy of endoscopic transpapillary nasopancreatic drainage (NPD) in patients with EPF.

METHODS

Over 12 years, 23 patients (19 males) with EPF underwent attempted endoscopic transpapillary NPD. The end points were fistula closure with healing of pancreatic duct disruption on nasopancreatogram, or need for surgery.

RESULTS

All 23 patients had persistent drain output (>50 mL/day) for >6 weeks. The mean output volume of the fistula was 223 mL (range: 60 mL to 750 mL). Sixteen patients had partial and seven patients had complete pancreatic duct disruption. The NPD could be successfully placed in 21/23 (91.3%) patients. Disruption was bridged in 15 of 16 patients with partial duct disruption. EPF healed in 2-8 weeks of placement of NPD in all of the patients with partial duct disruption that was bridged and there was no recurrence at a mean follow-up of 38 months. The EPF resolved in only 2/6 (33%) patients with complete duct disruption.

CONCLUSIONS

External pancreatic fistulas developing following percutaneous drainage of pancreatic fluid collections or surgical necrosectomy can be effectively treated by transpapillary nasopancreatic drain placement especially when there is partial ductal disruption and the disruption can be bridged.

Endoscopic retrograde cholangiopancreatography in patients with pancreatic trauma

BACKGROUND

: Pancreatic injury occurs in from 3% to 12% of patients with abdominal trauma. In many instances, a lack of impressive findings in the first 24 hours leads to a delay in diagnosis. Because pancreatic duct disruption is the major cause of traumatic pancreatitis, we evaluated our experience with endoscopic retrograde cholangiopancreatography (ERCP) in patients suspected of having of having pancreatic injury.

METHODS

: We reviewed the medical records of 26 patients evaluated perioperatively by ERCP for suspected pancreatic duct injury. The examinations were performed in the endoscopy suite or radiography special procedures or operating rooms under direct fluoroscopic control using fiberoptic or videooptic duodenoscopes.

RESULTS

: Seventeen men and nine women with a mean age of 32.8 +/- 2.2 years suffered severe abdominal trauma. ERCP was performed in these patients a mean of 19 +/- 11.3 days after trauma. Seven patients underwent ERCP just before or at laparotomy. Eight of 26 (31%) patients were found to have intact pancreatic and bile ducts, whereas 18 (69%) patients had substantial findings unsuspected by pre-ERCP imaging. Nine of these 18 patients with documented ductal injury underwent endoscopic treatment alone without further surgical intervention, including pancreatic sphincterotomies and/or pancreatic ductal stenting.

CONCLUSIONS

: ERCP is feasible and strongly indicated in the care of many patients with pancreatic trauma. Patient care and overall surgical and hospital needs may be substantially impacted by the use of both diagnostic and therapeutic endoscopic retrograde colongiopancreatography.

Endoscopic drainage and endoscopic necrosectomy in the management of symptomatic pancreatic collections

OBJECTIVE

To evaluate the role of endoscopic drainage and endoscopic necrosectomy in the management of symptomatic pancreatic fluid collection.

METHODS

The clinical data of patients with symptomatic pancreatic fluid collection referred for endoscopic drainage were captured prospectively and analyzed. Pancreatic duct disruption was treated with stenting. Endosonography-guided transmural drainage and endoscopic necrosectomy were performed when indicated.

RESULTS

Fifteen consecutive patients (mean age 53.7 years; range 23-82 years) underwent endoscopic management of pancreatic fluid collections (pseudocysts: six; abscesses: six; infected walled-off necrosis: three). Pancreatic duct fistulas were present in 13 patients. The drainage techniques used were: (i) transpapillary drainage; five; (ii) transmural drainage; two (these two patients had no pancreatic duct fistulas); and (iii) combined transpapillary and transmural drainage; eight. An additional transgastric endoscopic necrosectomy was performed in five patients. The endoscopic treatment was successful in all cases. The only complication was asymptomatic pneumo-peritoneum that occurred in one patient. Combined transpapillary and transmural drainage led to the faster resolution of the fluid collection compared to transpapillary drainage (75.6 vs 147 days, P = 0.03). No recurrence occurred over a mean follow up of 486 days.

CONCLUSION

Endoscopic drainage and endoscopic necrosectomy are safe and effective techniques for the treatment of symptomatic pancreatic fluid collection.

[Importance of endoscopy and endosonography for chronic pancreatitis and benign pancreas tumors]

Endoscopic retrograde pancreatography (ERP) and endoscopic ultrasound (EUS) are superior to cross-sectional imaging procedures for detection of low-grade pancreatitis, but detection of duct alterations is more reliable by middle and high-grade chronic pancreatitis than by low-grade. In addition to assessment of alterations in the pancreatic duct, EUS also allows detection of parenchymatous alterations. Because of the risk of post-ERP pancreatitis, ERP has been mostly eliminated from diagnostic procedures. In contrast, endoscopic retrograde cholangiopancreatography (ERCP) allows an unrivalled access to interventional treatment of inflammatory alterations of the biliopancreatic duct system, by retrograde, non-penetrable papillae even in the rendezvous procedure with EUS-assisted probing of the Ductus Wirsungianus. Despite the technical success of endoscopic procedures, surgical duct decompression has proven to be superior for relief from pancreatitic pain. Biliary drainage is also more likely to be successful on a permanent basis using surgical procedures than by repeat multi-stenting, at least by calcifying pancreatitis. Peroral transgastral transmural therapy of postpancreatitic necroses opens up further options over surgical removal of necroses.

Treatment of pancreatic pseudocysts, pancreatic necrosis, and pancreatic duct leaks

Pancreatic pseudocysts arise as a complication of acute and chronic pancreatitis or pancreatic trauma (including postsurgical). Pancreatic necrosis occurs following severe pancreatitis and may evolve into an entity termed organized pancreatic necrosis that is endoscopically treatable. Pancreatic duct leaks are frequently seen in relation to pseudocysts and necrosis. Alternatively, pancreatic duct leaks may present with pleural effusions, ascites, or after pancreatic surgery or percutaneous drainage. Endoscopic treatment of pancreatic fluid collections and pancreatic duct leaks can be achieved using transpapillary and/or transmural stent placement.