A 45-year-old man underwent distal pancreatectomy for chronic pancreatitis. Over the
ensuing 2 years he developed recurrent pancreatic fluid collections (PFCs) from pancreatic
duct leakage at the resection site. He underwent repeated surgery, percutaneous drainage,
and placement of pancreatic duct stents. Endoscopic transmural drainage was suggested
on several occasions but rejected by the surgical team.
Following recent pancreatic duct stent removal, left upper quadrant abdominal pain
recurred. Computed tomography showed a small, poorly defined peripancreatic collection.
Transgastric drainage was undertaken.
A linear-array echoendoscope was used to identify and puncture the PFC using a 19 G
fine-needle aspiration (FNA) needle. Under fluoroscopy, contrast was injected and
filled a long fistulous tract that communicated with the main pancreatic duct ([Fig. 1]). Attempted guidewire passage into the fistulous tract was unsuccessful. The echoendoscope
was removed and a duodenoscope was inserted. Endoscopic retrograde cholangiopancreatography
(ERCP) confirmed a pancreatic duct leak into the fistulous tract. In order to serve
as a target for endoscopic ultrasound (EUS)-guided puncture, a 10 – 12-mm dilating
balloon catheter was advanced over a guidewire through the pancreatic duct and into
the fistulous tract, in a procedure similar to that which has been described for EUS-guided
gastroenterostomy ([Video 1]) [1]. The balloon was inflated ([Fig. 2]), and the duodenoscope was removed from the mouth leaving the inflated balloon inside
the fistulous tract. As the endoscope could not be removed from the balloon catheter,
it was detached from the processor and placed alongside the patient. The echoendoscope
was reinserted alongside the balloon catheter. Using endosonographic and fluoroscopic
visualization, the balloon was identified from the stomach and punctured using a 19-G
FNA needle. A stiff 0.035-inch guidewire was coiled inside the fistulous tract. A
gastro-fistula anastomosis was created using a needle-knife and balloon dilator followed
by placement of two 7-Fr double-pigtail plastic stents.
Fig. 1 Fluoroscopic image demonstrating endoscopic ultrasound-guided contrast injection,
which filled the main pancreatic duct as well as the fistulous tract.
Endoscopic transgastric pancreatic fistula anastomosis as treatment for a refractory
pancreatic duct leak after distal pancreatectomy.
Fig. 2 The inflated balloon dilator within the fistula served as a target for endoscopic
ultrasound-guided puncture.
The patient, who underwent the treatment as an outpatient, tolerated the procedure
well. At follow-up 8 weeks later he remained well.
Endoscopy_UCTN_Code_TTT_1AR_2AI
