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IMAGES AND VIDEOS
Year : 2016  |  Volume : 5  |  Issue : 4  |  Page : 276-278

Endoscopic ultrasound-guided internalization of a pancreaticocutaneous fistula without need for percutaneous manipulation


1 Department of Gastroenterology, Centro Hospitalar So Joo, Porto, Portugal; Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
2 Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA

Date of Submission19-Nov-2015
Date of Acceptance15-Mar-2016
Date of Web Publication5-Aug-2016

Correspondence Address:
Todd Huntley Baron
Division of Gastroenterology and Hepatology, School of Medicine, University of North Carolina, 101 Manning Drive, Chapel Hill, NC 27514
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2303-9027.187895

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How to cite this article:
Rodrigues-Pinto E, Baron TH. Endoscopic ultrasound-guided internalization of a pancreaticocutaneous fistula without need for percutaneous manipulation. Endosc Ultrasound 2016;5:276-8

How to cite this URL:
Rodrigues-Pinto E, Baron TH. Endoscopic ultrasound-guided internalization of a pancreaticocutaneous fistula without need for percutaneous manipulation. Endosc Ultrasound [serial online] 2016 [cited 2020 Aug 14];5:276-8. Available from: http://www.eusjournal.com/text.asp?2016/5/4/276/187895

A 39-year-old male presented 9 months prior with acute alcoholic necrotizing pancreatitis. A 21 cm × 7cm walled-off pancreatic necrosis (WOPN) developed with main pancreatic duct disruption and upstream pancreatic ductal disconnection. A percutaneous pigtail drain was placed. After resolution of the collection, high volume output from the pancreaticocutaneous fistula remained. Endoscopic retrograde cholangiopancreatography showed complete main pancreatic duct obstruction [Figure 1]. A prophylactic pancreatic stent was placed. Contrast injection through the percutaneous drain filled the upstream pancreatic duct. EUS-guided internalization was undertaken. A linear echoendoscope (Olympus GFUCT-180, Center Valley, PA, USA) was positioned in the stomach. Endosonographically, the pigtail drain was visualized [Figure 2]. The residual cavity, marked by the internal pigtail was punctured transgastrically with a 19-gauge fine-needle aspiration needle (Expect, Boston Scientific, Marlborough, MA, USA) [Figure 3]. A 0.035" guidewire (450 cm Hydra Jagwire, Boston Scientific) was advanced through the needle and passed out the percutaneous tract. The gastric wall was balloon dilated to 6 mm (Hurricane™, Boston Scientific) [Figure 4]. The echoendoscope was removed; a standard side-viewing endoscope was introduced alongside the initial wire. A second guidewire was advanced and coiled inside the pigtail cavity [Figure 5]. The pancreaticogastrostomy was then stented with two 7 Fr 3 cm double pigtail stents [Figure 6]. The patient's percutaneous drain was removed during the procedure. The pancreaticocutaneous fistula output ceased several days later. There were no adverse events, and the patient was clinically well 4 months later.
Figure 1: Fluoroscopic image. Endoscopic retrograde cholangiopancreatography transpapillary wire placement shows a disconnected pancreatic duct with pancreatic acinarization. The percutaneous drain can be seen

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Figure 2: Endosonographc image. Visualization of the pigtail drain within a small cavity

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Figure 3: Fluoroscopic image. Percutaneous drain transgatric puncture under endosonographic guidance with pancreatogram of the tail of the pancreas and a small cavity around the drain

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Figure 4: Fluoroscopic image. Dilation of the pancreaticogastrostomy tract with 6 mm balloon

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Figure 5: Fluoroscopic image. Passage and coiling of a second guidewire into the cavity

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Figure 6: Fluoroscopic image. Stenting of the pancreaticogastrostomy with two 7 Fr 3 cm double pigtail plastic stents. A third, misdeployed stent is in the gastric lumen

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  Discussion Top


Necrotizing pancreatitis and WOPN can lead to complete duct disruption and subsequent main pancreatic duct disconnection. When percutaneous drainage is used as the sole modality for management WOPN, an external fistula can develop from the upstream pancreatic duct through the drain site after the collection resolves. Management options for these patients are long-term percutaneous drain placement or surgery, both associated with substantial morbidity. [1] While there are reports of pancreaticocutaneous fistula closure by injection of fibrin glue and cyanoacrylate into the tract, [2] adverse events can occur, and it does not provide a drainage solution for the functional, disconnected pancreatic gland. Previous rendezvous endoscopic and percutaneous approaches have been used to internalize pancreaticocutaneous fistula [3],[4] by directing pancreatic secretions back into the intestinal lumen allowing closure of the external pancreatic fistula. This prevents recurrent collections and potentially preserves the parenchymal function of the disconnected gland. However, to our knowledge, internalization of a pancreaticocutaneous fistula not been reported without using the percutaneous tract to pass needles across into the stomach. In our case a pancreaticocutaneous fistula secondary to a disconnected pancreatic duct was internalized using EUS-guidance. The use of a duodenoscope, while not mandatory may simplify the procedure, since side view, mechanics and maneuverability are better than with echoendoscopes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ridgeway MG, Stabile BE. Surgical management and treatment of pancreatic fistulas. Surg Clin North Am 1996;76:1159-73.  Back to cited text no. 1
    
2.
Seewald S, Brand B, Groth S, et al. Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate. Gastrointest Endosc 2004;59:463-70.  Back to cited text no. 2
    
3.
Arvanitakis M, Delhaye M, Bali MA, et al. Endoscopic treatment of external pancreatic fistulas: When draining the main pancreatic duct is not enough. Am J Gastroenterol 2007;102:516-24.  Back to cited text no. 3
    
4.
Irani S, Gluck M, Ross A, et al. Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: Using rendezvous techniques to avoid surgery (with video). Gastrointest Endosc 2012;76:586-93.e1-3.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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