Percutaneous management of chronic pancreatic duct strictures and external fistulas with long-term results

Image-Guided Percutaneous Pancreatic Duct Drainage: A 10-Year Observational Study

PURPOSE

To study the safety, efficacy, and long-term outcomes of percutaneous pancreatic duct drainage (PPDD) for treating pancreatic duct (PD) obstruction.

MATERIALS AND METHODS

This prospective observational cohort study included 73 patients with PD obstruction between December 2010 and June 2020. Patients underwent PPDD under ultrasound and fluoroscopy guidance, computed tomography (CT) and fluoroscopy guidance, or CT guidance only. They were categorized into 2 groups: nonmalignant (26 patients with PD obstruction due to acute and chronic pancreatitis or postoperative stricture) and malignant (47 patients with pancreatic head and ampullary tumors).

RESULTS

The overall technical success rate was 98.6% (72/73). No major complications were encountered; however, severe weakness, lack of appetite, and tachycardia were observed in 4.1% (3/73) of patients, managed with intravenous resuscitation. Multivariate analysis demonstrated that diagnosis type (pancreatic head tumor: P = .049; odds ratio = 1.95 [1.11-2.25], and chronic pancreatitis: P = .048; odds ratio = 6.25 [1.74-22.22]) was associated with mortality. The median survival time was 16.3 months. Moreover, 15.1% (11/73) of the patients were alive 4 years after the PPDD procedure, and the mean overall survival time of nonmalignant and malignant patients was 35.1 and 21.4 months, respectively.

CONCLUSIONS

Image-guided PPDD appears to be feasible and safe and provides a valuable therapeutic option for managing patients with PD obstruction.

Percutaneous Image-Guided Pancreatic Duct Drainage: Technique, Results and Expected Benefits

PURPOSE

The aim of this study is to provide a technical detail and feasibility of percutaneous image-guided pancreatic duct (PD) drainage and to discuss its subtleties in a series of patients with obstructed PD.

MATERIALS AND METHODS

Thirty patients presenting with PD obstruction from pancreatic head tumour or pancreatitis were subjected to percutaneous image-guided PD drainage under a guidance of ultrasound or computed tomography. Following the successful puncture of PD, a locking loop drainage catheter was placed using conventional guidewire techniques under real-time fluoroscopy guidance.

RESULTS

The percutaneous drainage of obstructed PD was completed in 29 (96.7%) patients as an independent therapeutic intent or as a bridge to further percutaneous procedures. Clinical improvement following drainage was documented by the gradual reduction in clinical symptoms, including pain, nausea and fever and improved blood test results, showing the significant decrease of amylase concentration. The amount of pancreatic fluid drained post procedure was between 300 and 900 mL/day. No major procedure-related complications were observed. Subsequently, 14 of 29 patients underwent further procedures, including endoluminal placement of metal stent with or without radiofrequency ablation, balloon assisted percutaneous descending litholapaxy (BAPDL), endoluminal biopsy and balloon dilatation using the same drainage tract.

CONCLUSION

The percutaneous PD drainage appears to be a safe and effective procedure. It should be considered in patients with obstructed PD secondary to malignancy, pancreatitis etc., where endoscopic retrograde cannulation has been failed or impracticable. The procedure can also be contemplated either as an independent treatment option or as an initial step for the subsequent therapeutic endoluminal procedures.

Percutaneous pancreatic-duct puncture with rendezvous technique can treat stenotic pancreaticojejunostomy

Stenotic pancreatico-enteric anastomosis is one of the serious late complications after a pancreaticoduodenectomy. We report a case of stenotic pancreaticojejunostomy with a pancreatic juice fistula drained externally, which was treated using percutaneous procedures combined with a rendezvous method. A 77-year-old woman was referred to our hospital for an endoscopic treatment to remove a percutaneous drainage tube from a fluid collection due to pancreatic juice fistula. She had undergone pylorus-preserving pancreatoduodenectomy with Roux-en-Y reconstruction due to duodenal carcinoma of Vater's papilla 1 year before the referral to our hospital. Soon after the operation, she had developed a fluid collection adjacent to the anastomosis due to pancreatic juice fistulas and subsequently had undergone its percutaneous drainage. After admission, we tried to dilate the stenotic anastomosis with an endoscopic procedure from the anastomosed jejunal lumen, using an oblique-viewing endoscope. The endoscope reached a portion of the anastomosis, but did not allow us to visualize the entire anastomosis. We punctured the main pancreatic duct under ultrasonography and fluoroscopy, and advanced the needle into the anastomosed jejunum through the stenotic anastomosis. After putting a guidewire into the anastomosed jejunum through the needle, we introduced an oblique-viewing endoscope into the anastomosed jejunum and caught hold of the guidewire using grasping forceps. Maintaining tension on the guidewire with a slight pulling force, with some effort we were able to place a 5-Fr drainage catheter into the jejunum percutaneously and through the anastomosis via the main pancreatic duct. Three weeks after these procedures, we performed balloon dilation of the anastomosis. One week after balloon dilation, removed the percutaneous catheter.

Percutaneous pancreatography for treatment of complicated pancreatic duct strictures

BACKGROUND

Percutaneous transhepatic cholangiography was developed over 30 years ago for the diagnosis of biliary disorders. It has become an accepted interventional technique for management of biliary tract diseases, especially in patients who have failed attempted endoscopic retrograde pancreatography or have altered anatomy that makes the biliary tree endoscopically inaccessible. The correlative procedure, which we term 'percutaneous pancreatography' (PP), has only been described once in the literature.

CASE PRESENTATIONS

We report the outcome of 4 patients undergoing PP for management of difficult pancreatic duct strictures. In all patients, PP was used to provide access and therapy of otherwise endoscopically impassable pancreatic duct strictures. PP-guided pancreatic stent duct placement was performed and allowed for subsequent successful endoscopic management of complex, benign pancreatic duct obstructions.

CONCLUSIONS

PP is a useful modality for management of otherwise endoscopically impassable pancreatic duct strictures.

Pancreatic Fistula

External and internal pancreatic fistulas have a different etiology and natural history. Approximately 50% of internal and 70% to 90% of external pancreatic fistulas can be expected to heal with nonoperative management. Nonclosure is predicted by anatomic factors, which may be defined at endoscopic retrograde cholangiopancreatography or by CT if disconnected pancreatic segments are seen. Enteral nutrition beyond the ligament of Treitz is probably as effective as total parenteral nutrition in reducing fistula output. Octreotide reduces output and, possibly, time to closure. It does not increase the incidence of closure, and there is no convincing evidence that it prevents significant postoperative leaks. Endoscopic stenting has been reported to be effective treatment for side leaks, particularly when associated with stenoses or calculi. However, it is not widely available and has a significant complication rate related to pancreatic sphincterotomy and stent blockage. Surgical treatment is indicated for end leaks with a disconnected pancreatic segment. The choice of appropriate procedure is important. Percutaneous interventional therapies are emerging as options for treatment of end leaks but are still investigational.

Interventional radiological treatment in complications of pancreatitis

Percutaneous interventional therapy plays an important role in treating complications of acute and chronic pancreatitis. With the development of cross-sectional imaging and advanced interventional techniques, percutaneous drainage has become the preferred treatment for pancreatic fluid collections such as acute collections, pseudocysts and abscesses. Abscess and pancreatic hemorrhage are the most life threatening complications of pancreatitis. Massive hemorrhage is rare but frequently lethal. As a rule, bleeding complications of pancreatitis require prompt diagnosis and an aggressive surgical approach. In unstable patients with a severely bleeding pseudoaneurysm, hemostasis can be obtained by occlusion with mechanical devices.