Endoscopic therapy for pancreatic fistulae
INTRODUCTION: Case reports and small series have indicated that endoscopic therapy for pancreatic fistulae (PF) may be successful. This series reviews the experience with PF at a tertiary care referral center. METHODS: A retrospective review of the DUMC endoscopic database between 09/30/87 and 09/30/95 identified 28 PF cases. Follow up was obtained for 25 patients ranging from 2 mths to 5 yrs (median 15 mths). RESULTS: Types of PF noted were pancreatoduodenal (PD)(11). pancreatoperitoneal (PT)(11), pancreatocutaneous (PC)(3), pancreatobiliary (PB)(2), and pancreatopleural (PP)(2). Patient characterisitics included: mean age 47.1 yrs, 61% male, 71% white, 25% African-American, and 4% Asian-American. Of the 66 ERCP performed (mean 2.4 ERCP/patient), 31 (47%) were therapeutic. Technical success was 98% for diagnostic and 94% for therapeutic ERCP PF etiology included: acute pancreatitis (9), chronic pancreatitis (8), pancreatic cancer (2), and iatrogenic (9) (7 post-pancreatic surgery, 1 post-operative biopsy, and 1 post-ERCP). Alcohol abuse was a major factor in 12 of 28 (43%) cases. Type and result of endoscopic therapy, as well as need for surgical therapy for each type of PF are noted below: PF Cases ERCP Type of Result of Adjunctive Surg. Type (#) (#) ERCP Rx*(#) ERCP Rx**/(#) Rx***#) Rx(#) PD 10 6 ST9, SP2, SEI C2, P 2, F 1. U1 0 3 PT 11 10 ST10, SP 1, NPD 1 C 5, P 2, F 2, X 1 10 4 PC 3 1 ST 3 C1 3 0 PB 2 1 ST 1 P 1 1 2 PP 2 1 ST 2 C 11*ST-stent, SP-sphincterotomy, SE-stone extraction, NPD=nasopancreatic drain.**C-complete success, P-partial success, F=faiture, U-unknown, X=insufncient trial***includes: TPN, distal enteric feeding, octreotide, percutaneous drainage Overall success rate for endoscopy therapy was 14/19 = 74% (47% complete, 26% partial). Ten of 28 cases (36%) ultimately required surgery (7 of 10 had prior endoscopic therapy). CONCLUSIONS: 1) In this series, 47% of PF were successfully managed with endoscopic ± adjunctive therapy. In an additional 26% of PF, a partial response to these therapies was noted 2) Adjunctive therapies are routinely used in all PF, save for PD, and may be integral to the success of nonsurgical management.
Maniatis, AG; Roman, R; Branch, MS; Jowell, PS; Affronti, J; Pappas, T; Baillie, J
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