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• W1540995645 abstract "See article in J. Gastroenterol. Hepatol. 2010; 25: 1087–1092 External pancreatic fistula (EPF), also called pancreaticocutaneous fistula, is a reported complication in 38% of patients undergoing pancreatic resection,1 10% after necrosectomy, and 20% after pseudocyst drainage.2 Thus, EPF results from injury during pancreatic resection for pancreaticoduodenal trauma, debridement for necrotizing pancreatitis, and percutaneous drainage for communicating pseudocysts. Although the exact pathogenesis is unclear, parenchymal necrosis that might disrupt the small or even the larger pancreatic ducts is considered as the most crucial factor.3, 4 Clinically, most patients with an EPF present with fistulas pouring low or moderate output volumes that are not life threatening,3 but occasionally serious complications occur. These include abscess, bleeding from the fistulous tract, and sepsis secondary to abscess formation; the latter is usually associated with high fistulous output, and mortality in such complicated cases is 13%–36%.3-5 In patients afflicted with low fistulous output EPF, conservative management is appropriate. This includes nil by mouth, total parenteral nutrition, and administration of inhibitors of pancreatic secretion, such as somatostatin or its analog. Such ‘conservative management’ leads to spontaneous closure of the fistula in 40%–90% of cases. The reason why there is a wide reported range for the successful achievement of EPF closure might be because studies have been based on small case numbers and have employed several therapeutic modalities.5 Conservative therapy is aimed at decreasing endogenous pancreatic secretion so that flow through the fistula will diminish, allowing the fistula to close. However, some EPF cases are refractory to conservative treatment. Predictors of this refractoriness to conservative therapy include low serum sodium and albumin, a high fluid-to-serum total protein ratio, and co-existence of severe chronic pancreatitis at endoscopic retrograde cholangiopancreatography.4 In patients with EPF complicating chronic pancreatitis, unfavorable anatomy of disruption, stenosis, and the narrowing of the pancreatic duct could disturb the closure of the fistula or lead to early recurrence.3, 4 Surgery is considered as the next step when EPF persists for a prolonged period, despite conservative management. For instance, if the fistula has not closed within a 2–4-week trial of conservative management, surgery should be considered.4 The choice of operation depends on the site of the leak and the presence of any associated pathology of the main pancreatic duct. In practice, conservative medical therapy is unsatisfactory in a significant proportion of cases, while surgical treatment is associated with significant morbidity and mortality,6 prolonged hospitalization, and high medical costs. In these adverse situations, endoscopic intervention could be the solution for the treatment of EPF. As the experience of endoscopists has accrued and technical advances in endoscopic instruments have progressed, endotherapy for EPF can now be considered as a first-line therapeutic modality. Even with complex forms of EPF, endotherapy can be attempted instead of surgery.4, 5, 7-9 There are two opposite premises in endotherapy: one is that most ductal disruptions will close and heal if ductal continuity is re-established and the pressure gradient is abolished through pancreatic sphincterotomy, stone removal, stricture dilation, and pancreatic stenting; the other is that ductal disruption might never heal without correction of the downstream obstruction.10 While existing data are limited to a few studies, the results of pancreatic endotherapy for EPF to date are encouraging. Kozarek et al.7, 11 demonstrated a way to correct the disrupted pancreatic duct. They decompressed it by performing either a pancreatic sphincterotomy or placing a pancreatic stent; this enables the pancreatic fluid to flow into the low-pressure gut, providing an opportunity to close the leak. Instead of stent insertion, in which early stent blockage and infection could develop,7, 11 nasopancreatic drainage (NPD) is preferred after sphincterotomy because the NPD can decrease the pancreatic duct pressure to levels less than those of the duodenum.12 This NPD also allows a pancreaticogram to be used to check duct patency and leaks when needed.4 For these reasons, some authors4, 12 prefer an NPD rather than stent, in spite of the fact that stent placement is more comfortable for patients. However, complete disruption of the main pancreatic duct or non-bridging of the ductal leak in the presence of a tight stricture or obstruction are limiting factors for achieving successful endotherapy, irrespective of stent or NPD.4 In this issue of Journal of Gastroenterology and Hepatology, Rana et al.13 report their interesting experience of 12 years of EPF treatment. The technology used was endotherapy with placement of transpapillary NPD after failure of initial conservative management. In their trial, all 23 patients had persistent drain outputs >50 mL/day for 6 weeks, and 16 patients had partial pancreatic duct disruption at endoscopic retrograde pancreatography. Bridging the duct was successfully done in 15 patients. The EPF closed in 2–8 weeks with NPD placement in this subgroup, and there was no recurrence at a mean follow-up period of 38 months. However, success of EPF closure was achieved in only two of six (33%) patients who had complete duct disruption. Procedure-related complications were observed in only two cases. Costamagna et al.4 have also reported results of endoscopic transpapillary NPD placement in 16 patients with postsurgical external pancreatic fistula. Technical success was achieved in 12 of 16 (75%), and fistula closure was achieved in 11 of these 12 patients after NPD placement. Cicek et al.12 reported a similar success rate in their series of 26 patients (EPF in 23 patients). Conclusively, the overall success rate of fistula closure in Rana et al.'s study was 17 of 23 (74%), which is comparable to other studies. The limitation of endotherapy is cases with complete duct disruption, in which the success rate is very low and surgical management is required in most cases.12, 14 It is our cautious conclusion that surgery should be considered as an initial therapy in non-bridging complete duct disruption. Recently, secretin-enhanced dynamic magnetic resonance pancreatography was developed to visualize pancreatic duct disruption and help the clinician decide whether or not to perform endotherapy.12 The timing of endotherapy in EPF is still controversial. Since conservative therapy requires prolonged hospitalization, is of considerable cost, and usually results in poor quality of life, other modalities, including endotherapy, should be encouraged. However, the morbidity and mortality of therapeutic endoscopy in critically ill patients should also be considered, and spontaneous EPF closure is obvious in a significant proportion of patients. Boerman et al.15 reported a good result of early endoscopic intervention of EPF, although they did not specify the exact time interval after necrosectomy. In conclusion, the results of the study reported by Rana and colleagues in this issue of Journal of Gastroenterology and Hepatology is encouraging;13 it confirms that endoscopic treatment of patients with EPF can often avoid an aggressive surgical approach and could be useful as a first-line therapy when conservative treatment is unsuccessful. Precise knowledge of pancreatic duct anatomy is mandatory to ensure technical success, and this procedure should be performed by an expert. In the near future, we hope that randomized controlled trials on feasibility and efficacy of early endoscopic intervention for EPF will be reported with results that definitely warrant its position as a second-to-none choice." @default.
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• W1540995645 date "2010-05-26" @default.
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• W1540995645 title "Endotherapy of external pancreatic fistula: Second-to-none choice for cure" @default.
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• W1540995645 doi "https://doi.org/10.1111/j.1440-1746.2010.06294.x" @default.
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