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. (C) 2019 IAP and EPC. Published by Elsevier B.V. All rights reserved. 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. (C) 2019 IAP and EPC. Published by Elsevier B.V. All rights reserved.