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• W2945278001 abstract "We read with interest the retrospective series of Jürgensen et al1Jürgensen C. Distler M. Arlt A. et al.EUS-guided drainage in the management of postoperative pancreatic leaks and fistulas (with video).Gastrointest Endosc. 2019; 89: 311-319Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar reporting on 196 patients presenting with postoperative pancreatic leaks or fistulas, managed with endoscopic or surgical means. The authors and the associated editorial2Saar M.G. Endoscopic drainage of postoperative pancreatic leaks: A great idea!.Gastrointest Endosc. 2019; 89: 320-321Google Scholar focus on the novelty of including patients with no adjacent collection (n = 64), either because there is a preexisting surgical drain in place or in the setting of an external pancreatic fistula (EPF) without any external drain in place. They describe the technique of internalizing the external drainage by an EUS-guided transmural puncture of the fistula tract, facilitated by injection of contrast material or saline solution through the external drain until a collection has been recreated. The authors refer to only 2 previous publications, including, respectively, 4 patients3Haseeb A. Abu Dayyeh B.K. Levy M.J. et al.Endoscopic ultrasound-guided treatment of pancreaticocutaneous fistulas.ACG Case Rep J. 2016; 3: e105Google Scholar and 15 patients4Irani S. Gluck M. Ross A. et al.Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video).Gastrointest Endosc. 2012; 76: 586-593Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar with EPF treated with endoscopic and percutaneous rendezvous techniques. One of these4Irani S. Gluck M. Ross A. et al.Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video).Gastrointest Endosc. 2012; 76: 586-593Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar described a non–EUS-guided procedure consisting of an outside-in transmural puncture (through the fistula tract to the digestive lumen) with the help of a transjugular intrahepatic portosystemic shunt needle, in 10 patients presenting with EPF, no collections, and a previous EUS-guided approach that failed because of the lack of a visible or accessible collection. As already acknowledged in the publication from Irani et al,4Irani S. Gluck M. Ross A. et al.Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video).Gastrointest Endosc. 2012; 76: 586-593Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar our group published the first report on these EUS or non–EUS-guided techniques more than 10 years ago.5Arvanitakis M. Delhaye M. Bali M.A. et al.Endoscopic treatment of external pancreatic fistulas: when draining the main pancreatic duct is not enough.Am J Gastroenterol. 2007; 102: 516-524Crossref PubMed Scopus (41) Google Scholar In this initial report we included 15 patients with EPF in whom the use of a transjugular intrahepatic portosystemic shunt needle was applied in 3 patients, and the re-creation of a virtual collection (through transient injection of saline solution) followed by EUS-guided drainage was performed in 2 patients. An accompanying editorial underlined the use of these techniques to internalize an external drainage and healing the EPF by inversing the pressure gradient.6Cohen S.A. Siegel J.H. Endotherapy for pancreatic fistulae: inside out or outside in?.Am J Gastroenterol. 2007; 102: 525-526Crossref PubMed Scopus (5) Google Scholar Furthermore, all the described techniques, combining endoscopic and percutaneous accesses, were completed by the same operators, in the endoscopy suite, during a single procedure. Obviously, even if performed in several centers and referenced in review articles,7Varadarajulu S. Rana S.S. Bhasin D.K. Endoscopic therapy for pancreatic duct leaks and disruptions.Gastrointestinal Endosc Clin N Am. 2013; 23: 863-869Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar these techniques, which considerably improve the outcomes in patients with pancreatic leaks, sometimes require many years to be widely adopted by the surgical community, and it is encouraging to see such a large series where the endoscopic approach has been prioritized.1Jürgensen C. Distler M. Arlt A. et al.EUS-guided drainage in the management of postoperative pancreatic leaks and fistulas (with video).Gastrointest Endosc. 2019; 89: 311-319Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Having now practiced these procedures in a multidisciplinary environment for more than 15 years, we would like to underline some important features for the management of pancreatic leaks. As described by Jürgensen et al,1Jürgensen C. Distler M. Arlt A. et al.EUS-guided drainage in the management of postoperative pancreatic leaks and fistulas (with video).Gastrointest Endosc. 2019; 89: 311-319Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar EUS-guided transmural drainage should be the preferred approach, when feasible, in either the presence or the absence of a pancreatic collection, offering better results than percutaneous or surgical drainage through the fact that it creates an internal fistula.8Gupta T. Lemmers A. Tan D. et al.EUS guided transmural drainage of post-operative collections.Gastrointest Endosc. 2012; 76: 1259-1265Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar This is even more true when the leak is associated with a disconnected pancreatic tail syndrome in the setting of severe acute pancreatitis.9van Brunschot S. van Grinsven J. van Santvoort H.C. et al.Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial.Lancet. 2018; 391: 51-58Abstract Full Text Full Text PDF PubMed Scopus (326) Google Scholar In these cases, it is probably not indicated to systematically remove the transgastric stents after a few months because they maintain drainage from an isolated pancreatic segment.10Arvanitakis M. Delhaye M. Bali M.A. et al.Pancreatic fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage.Gastrointest Endosc. 2007; 65: 609-619Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar The use of metal stents for drainage of collections should also be avoided in these cases because they cannot be left in place for longer periods without the risk of adverse events. Finally, dynamic MRCP10Arvanitakis M. Delhaye M. Bali M.A. et al.Pancreatic fluid collections: a randomized controlled trial regarding stent removal after endoscopic transmural drainage.Gastrointest Endosc. 2007; 65: 609-619Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar, 11Matos C. Cappeliez O. Winant C. et al.MR imaging of the pancreas: a pictoral tour.Radiographics. 2002; 22: e2Crossref PubMed Scopus (82) Google Scholar is a useful tool to assess whether an endoscopically created internal pancreatic fistula still allows the drainage of pancreatic juice or whether a disconnected duct is present and to decide whether plastic stent removal should be planned. Even if an early endoscopic approach considerably decreases the duration of hospitalization and increases the quality of life of these patients with pancreatic leaks, preventing long-term recurrence by maintaining internal drainage when indicated is paramount. The authors disclosed no financial relationships relevant to this publication. EUS-guided drainage in the management of postoperative pancreatic leaks and fistulas (with video)Gastrointestinal EndoscopyVol. 89Issue 2PreviewPostoperative pancreatic leakage and fistulae (POPF) are a leading adverse event after partial pancreatic resection. Treatment algorithms are currently not standardized. Evidence regarding the role of endoscopy is scarce. Full-Text PDF ReplyGastrointestinal EndoscopyVol. 89Issue 6PreviewThank you for the valuable comments of Arvanitakis and Devière1 on our article about treatment of postoperative pancreatic fistulas.2 Indeed, their article3 described the internalization of pancreatic fistulas either by external-to-internal transmural puncture with TIPS instruments as used by Irani et al4 or by the internal EUS-guided drainage of an externally filled fistula channel by the re-creation of a puncturable fluid collection similar to our technique. Notably, and as in our study, most of their patients experienced fistulas after pancreatic surgery. Full-Text PDF" @default.
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• W2945278001 title "Postoperative pancreatic leaks and fistulas: beyond EUS-guided drainage of collections" @default.
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