Endoscopic stent placement for pancreaticocutaneous fistula after surgical drainage of the pancreas

Abstract

Background: Spontaneous closure of an external pancreatic fistula is unlikely when a concomitant downstream obstruction of the pancreatic duct inhibits downstream flow. Early endoscopic retrograde pancreatography (ERP) and stent insertion may enhance fistula closure in these patients. Methods: The results of endoscopic stenting of the pancreatic duct were evaluated in 15 patients with an external pancreatic fistula that developed after operative necrosectomy and debridement of the pancreas (seven men and eight women, median age 45 (range 25-68)years). Results: Median drainage before ERP was 50-800 ml/day, with an amylase content of 21 000-493 000 units/l. ERP was performed after a median time of 35 days and revealed leakage of the duct and a downstream obstruction in all patients. An endoprosthesis was inserted beyond the site of obstruction. Within a median time of 10 (range 2-64) days drainage stopped in all patients. In one patient ERP failed and pancreaticojejunostomy was performed. During follow-up (median 24 (range 2-55)months) three patients required resection of the pancreatic tail because of pseudocyst formation, all of whom originally had leakage from the tail area. Conclusion: Based on these data, an active approach for external pancreatic fistula seems warranted. Early ERP and stent insertion enhances fistula resolution, facilitates wound care and surgery is postponed or even avoided.