Successful treatment of pancreatobiliary fistula by endoscopic stenting

Pancreatic choledochal fistula complicating acute pancreatitis

Background:

Biliary tract involvement in acute necrotizing pancreatitis is rare.

Case Report:

We report a case of a 53-year-old man who had a pancreatic choledochal fistula complicating acute necrotizing pancreatitis. The fistula was suspected at computed tomography and confirmed at surgery. The patient underwent necrosectomy, cholecystectomy and proximal biliary diversion. He is well at 1-year follow-up.

Conclusions:

Simultaneous presence of air in the biliary tree and pancreatic collection is highly suggestive of a pancreaticobiliary fistula. Pancreatic necrosectomy and proximal biliary diversion resulted in closure of the fistula.

Direct peroral cholangioscopy and pancreatoscopy for diagnosis of a pancreatobiliary fistula caused by an intraductal papillary mucinous neoplasm of the pancreas: a case report

Here, we report a case of a pancreatobiliary (PB) fistula caused by an intraductal papillary mucinous neoplasm (IPMN) of the pancreas. The PB fistula was suspected after endoscopic retrograde cholangiopancreatography (ERCP) and diagnosed after direct visualization with a direct peroral cholangioscopy and pancreatoscopy by using an ultra-slim endoscope. No previous reports exist on the precise diagnosis of a PB fistula with direct peroral cholangioscopy and pancreatoscopy. In our case report, a 69-year-old man underwent an ERCP because of a pancreatic head mass and biliary tract obstruction. During ERCP, a fistula between the common bile duct (CBD) and main pancreatic duct (MPD) was suspected. After endoscopic sphincterotomy, we examined both the CBD and MPD with an ultra-slim videoendoscope (GIF-N260; Olympus Optical Co, Tokyo, Japan) under direct visualization and biopsy of the mass. The analysis of the biopsy specimen confirmed this mass to be an IPMN of the pancreas. When we examined the CBD, one fistula with copious mucin secretion was identified at the distal CBD. In conclusion, direct peroral cholangioscopy and pancreatoscopy using the ultra-slim endoscope is an efficient tool for diagnosis of PB fistula and pancreatic IPMN.

Pancreaticobiliary fistula evident after ESWL treatment of pancreatolithiasis

Here we report a patient with a pancreaticobiliary fistula that was possibly associated with pancreatolithiasis. He was admitted due to mild pancreatitis. Pancreatolithiasis was revealed in the parenchyma of the head region and in the main pancreatic duct of the pancreas body with distal dilatation. Extracorporeal shock wave lithotripsy (ESWL) effectively eliminated the pancreatic stones; however, an apparent internal fistula from the middle portion of the common bile duct (CBD) to the main pancreatic duct was revealed where the parenchymal stones had been located. The patient was considered to be in the same condition as pancreato-biliary malunion without CBD dilatation, and was treated with laparoscopic cholecystectomy.

Biliopancreatic fistula with portal vein thrombosis caused by a pancreatic pseudocyst

We encountered a very rare case of biliopancreatic fistula with portal vein thrombosis caused by pancreatic pseudocyst. A 57-year-old man was referred to our hospital because of abdominal pain, obstructive jaundice, and portal vein thrombosis due to acute pancreatitis. Computed tomography showed a 7-cm-diameter pseudocyst around the superior mesenteric vein extending towards the pancreatic head, dilatation of the intrahepatic bile duct, and portal vein thrombosis. Endoscopic retrograde pancreatography revealed a main pancreatic duct with a pseudocyst communicating with the common bile duct. After pancreatic sphincterotomy, a 7-F tube stent was endoscopically placed into the pseudocyst. However, a 6-F nasobiliary tube could not be inserted into the bile duct because the fistula had a tight stenosis. Subsequently, the patient's abdominal pain improved, the pancreatic cyst disappeared, and the serum amylase level normalized. Two months after the endoscopic retrograde cholangiopancreatography, percutaneous transhepatic biliary drainage was required because the patient's jaundice became aggravated. Two weeks after the choledochojejunostomy, the patient left the hospital in good condition. A follow-up computed tomography showed cavernous transformation of the portal vein and no pancreatic pseudocyst. The patient remains asymptomatic for 2 years and 7 months after surgery. Biliary drainage may be necessary for biliopancreatic fistula with obstructive jaundice in addition to pancreatic cyst drainage. Biliopancreatic fistula can be treated by endoscopic procedure in some cases; however, surgical treatment should be required in cases that are impossible to insert a biliary stent because of hard stricture.

Biliary pancreatic portal fistula as a complication of chronic pancreatitis: a case report with review of the literature

In this study we describe an unusual complication in a patient suffering from chronic calcifying pancreatitis. The patient had a fistula between the common bile duct, the pancreatic duct, and the portal vein. He received supportive medical treatment and achieved long-term survival. A review of the literature including diagnosis, treatment and outcome of this rare complication is presented.