External pancreatic fistula treated by endoscopic ultrasound-guided drainage with a novel lumen-apposing metal stent mounted on a cautery-tipped delivery system

 

 Permissions and Reprints

One of the most common causes of external pancreatic fistula is the iatrogenic manipulation of a complex pancreatic fluid collection concomitantly associated with a disconnected pancreatic duct [1] [2]. This situation can lead to the development of a high output (up to 400 mL/d) external pancreatic fistula that is difficult to manage and sometimes requires surgery [3].

In 2012, a 40-year-old woman underwent laparoscopic cholecystectomy with a hepaticojejunal Roux-en-Y anastomosis for a congenital Todani’s type IV common bile duct cyst. Postoperative pancreatitis resulted in the development of a complex pancreatic fluid collection in the pancreatic head, which was drained percutaneously. Subsequently, an external pancreatic fistula formed with an output of 200 mL/d.

In 2014, the patient was referred to us for further evaluation. Endoscopic retrograde cholangiopancreatography (ERCP) showed a normal main pancreatic duct that lacked a clear communication with the collection ([Fig. 1]). The injection of contrast through the percutaneous catheter showed the presence of a 4-cm fluid collection ([Fig. 2]). Endoscopic ultrasound (EUS)-guided drainage with the placement of plastic stents was planned.

At EUS, the collection was accessed from the duodenal bulb with a 19-gauge needle, after which a 0.035-inch guidewire was placed. The needle was then exchanged for an 8.5-Fr cystotome, but the collection no longer appeared adjacent to the duodenal wall, probably because it had been pushed away by the guidewire, and major vessels were interposed ([Video 1]). Based on our previous experience, we decided to replace the cystotome with a novel cautery-tipped stent delivery system that allows the single-step EUS-guided placement of a lumen-apposing fully covered metal stent (Hot AXIOS System; Xlumena, Mountain View, California, USA) [4]. The lesion was directly punctured and entered with the system, and an 8 × 8-mm lumen-apposing fully covered metal stent was delivered under complete EUS guidance ([Fig. 3], [Video 1]).

The output significantly dropped the following day, allowing removal of the external catheter 2 days after the procedure. The patient was discharged and remains well 3 months later, without any symptoms.

Endoscopy_UCTN_Code_TTT_1AS_2AD

• References

• 1 Neff R. Pancreatic pseudocyst and fluid collections: percutaneous approaches. Surg Clin North Am 2001; 81: 399-403
  CrossrefPubMedGoogle Scholar
• 2 Tann M, Maglinte D, Howard TH et al. Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients. J Comput Assist Tomogr 2003; 27: 577-582
  CrossrefPubMedGoogle Scholar
• 3 Ridgeway MG, Stabile BE. Surgical management and treatment of pancreatic fistulas. Surg Clin North Am 1996; 76: 1159-1173
  CrossrefPubMedGoogle Scholar
• 4 Galasso D, Baron TH, Attili F et al. Endoscopic ultrasound-guided drainage and necrosectomy of walled-off pancreatic necrosis using a metal stent with an electrocautery-enhanced delivery system. Endoscopy 2015; 47 (Suppl. 01) E68
  Article in Thieme ConnectPubMedGoogle Scholar