External pancreatic fistulae (EPF) are therapeutic challenge. Endoscopic therapy has shown encouraging results but experience is limited.
AIM: To study efficacy of endoscopic transpapillary nasopancreatic drainage alone in management of patients with EPF following percutaneous drainage of pancreatic fluid collections.
Methods: Over period of 10 years, seventeen patients (15-46 years, 13M) with EPF underwent attempted endoscopic transpapillary nasopancreatic drainage. All patients had developed EPF following unsuccessful percutaneous drainage of pancreatic fluid collections (14 with pseudocysts and 3 with acute fluid collections). An informed consent was obtained and endoscopy retrograde pancreatography (ERP) was performed. Pancreatic duct was selectively cannulated and pancreatogram obtained. A 5F / 7F nasopancreatic drain (NPD) was placed across/near site of pancreatic duct disruption over 0.025/0.035 inch hydrophilic guide wire through major or minor papilla. End points were fistula closure with healing of pancreatic duct disruption on nasopancreatogram or need for surgery.
Results: Six patients had underlying chronic pancreatitis (alcohol: 5 and idiopathic: 1) and 11 patients had acute pancreatitis (trauma: 8, gallstones: 2, and drugs: 1). The output volume ranged from 60 ml to 750 ml/day. Eleven patients had partial and six patients had complete pancreatic duct disruption. The site of pancreatic duct disruption was head in five patients (29.4%), body in ten patients (58.8%) and tail in two patients (11.7%). The NPD was successfully placed in 15/17 (88.2%) patients. In two patients, deep cannulation of pancreatic duct could not be achieved and they underwent surgery. Pancreatic duct disruption was bridged in 11 of 15 patients, all of whom had partial disruption and EPF healed in 2-8 weeks in all these 11 patients. There were no post procedure complications. In four patients, who had complete duct disruption, disruption could not be bridged. Two of these four patients with complete duct disruption, had successful outcome at 6 and 8 weeks respectively but one developed pseudocyst in follow up and was treated by surgery and second had a massive bleed form pseudo aneurysm 2 months after successful outcome and required surgery. Remaining two patients needed surgery because of non-resolution of EPF at 8 weeks. There was no recurrence of fistula in 11 successfully treated patients over a follow up of 6-96 months.
Conclusion: External pancreatic fistulae can be effectively treated by endoscopic retrograde pancreatography and transpapillary nasopancreatic drain placement especially when there is partial ductal disruption and the disruption can be bridged