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Title Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic duct dilation after pancreaticsurgery
Author(s) Onodera, Manabu; Kawakami, Hiroshi; Kuwatani, Masaki; Kudo, Taiki; Haba, Shin; Abe, Yoko; Kawahata, Shuhei;Eto, Kazunori; Nasu, Yuya; Tanaka, Eiichi; Hirano, Satoshi; Asaka, Masahiro
Citation Surgical Endoscopy, 26(6), 1710-1717https://doi.org/10.1007/s00464-011-2097-z
Issue Date 2012-06
Doc URL http://hdl.handle.net/2115/52926
Rights The original publication is available at www.springerlink.com
Type article (author version)
File Information SE26-6_1710-1717.pdf
Hokkaido University Collection of Scholarly and Academic Papers : HUSCAP
Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic
duct dilatation after pancreatic surgery
Manabu Onodera 1)
, Hiroshi Kawakami 1)
, Masaki Kuwatani 1)
, Taiki Kudo 1)
, Shin Haba 1)
Yoko Abe 1)
, Shuhei Kawahata 1)
, Kazunori Eto 1)
, Yuya Nasu 2)
, Eiichi Tanaka 2)
, and Masahiro Asaka 1)
1) Department of Gastroenterology, Hokkaido University Graduate School of Medicine
2) Department of Surgical Oncology, Hokkaido University Graduate School of Medicine
Author contributions: Onodera M and Kawakami H contributed equally to this work
Address correspondence to: Hiroshi Kawakami, MD, PhD.
Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo,
Fax: +81-11-706-7867 (ext.5918)
Running title: EUS-TD of pancreatic fistula
Key words: EUS-guided drainage, EUS-guided transmural drainage, pancreatic fistula, stasis
of pancreatic juice, pancreatic surgery
Background Endoscopic ultrasound (EUS)-guided drainage is widely used to manage
pancreatic pseudocysts. Several studies have reported the use of EUS-guided drainage for
pancreatic fistula and stasis of pancreatic juice caused by stricture of the pancreatic duct after
Methods In total, 262 patients underwent surgery involving pancreatic resection in our hospital
from April 2005 to March 2010. Ninety patients (34%) developed a grade B or C postoperative
pancreatic fistula (POPF) that required additional treatment. We performed EUS-guided
transmural drainage (EUS-TD) for six patients (2.1%) with a pancreatic fistula or dilatation of
the main pancreatic duct visible by EUS. Eighteen patients (6.8%) received percutaneous
drainage. The success rates of EUS-TD and percutaneous drainage were compared in a
Results EUS-TD was successfully performed without complications in all six cases, with five
of the six patients being successfully treated with only one trial of EUS-TD. The final technical
success rate was 100% for EUS-TD and for percutaneous drainage. Both the short-term and
long-term clinical success rates of EUS-TD were 100%, and those of percutaneous drainage
were 61.1% and 83%, respectively. The differences in these rates were not significant
(short-term success, P = 0.091; long-term success, P = 0.403). However, the period to clinical
success was significantly shorter with EUS-TD (5.8 days) than with percutaneous drainage
(30.4 days; P = 0.0013) in our series.
Conclusions EUS-TD appears to be a safe and technically feasible alternative to percutaneous
drainage and may be considered a first-line therapy for pancreatic fistulas visible by EUS.
CT, computed tomography; EUS, endoscopic ultrasound; EUS-TD, EUS-guided transmural
drainage; MPD, main pancreatic duct; POPF, postoperative pancreatic fistula; US, ultrasound;
DPDS, Disconnected pancreatic duct syndrome
Postoperative pancreatic fistula (POPF), a serious and potentially lethal complication, is the
main unsolved problem in pancreatic surgery. The principle underlying this treatment is
drainage of the pancreatic fluid that has collected within the abdominal cavity. The surgeon
usually places the drainage tube near the pancreatic stump or the anastomotic site of
pancreatoenterostomy to drain the collected fluid in cases of leakage (pancreatic fistula).
However, additional drainage may be needed when the drainage work during the operation is
inadequate. Despite the expansive growth pattern of pancreatic pseudocysts followed by acute
or chronic pancreatitis, the POPF space extends to the peritoneal cavity between visceral
organs. This space is usually located deep in the peritoneal cavity and it has an irregular and
complex shape. These caused treatment with both surgical and interventional ultrasound (US)
or computed tomography (CT)-guided drainage procedures to be problematic. The incidence
of postoperative pancreatic fistula (POPF) has been reported to be 5–20% after
pancreaticoduodenectomy and is associated with high mortality . The Japanese Society of
Hepato-Biliary-Pancreatic Surgery reported that the rate of POPF after
pancreaticoduodenectomy was 30.2% . Even with recent advances in pancreatic surgery,
POPF remains the major contributor to morbidity after pancreatic resection.
The treatment of choice for POPF is external or internal drainage of pancreatic juice, which
can be accomplished by surgical drainage, image-guided percutaneous drainage, or endoscopic
drainage. A surgical cyst-enteric anastomosis has traditionally been performed, with high
morbidity rates ranging from 7 to 37% [2, 3]. Percutaneous drainage offers satisfying results,
but it requires a long therapy period (several weeks to months) owing to the indwelling catheter
and is occasionally associated with the formation of an external fistula [4, 5]. Furthermore,
cutaneopancreatic fistulas that form after percutaneous drainage are usually intractable.
Endoscopic drainage has been performed increasingly during the last 10 years [6–8].
Two approaches have been used for endoscopic access: through the gastrointestinal wall by
creating a cystogastrostomy/cystoduodenostomy (transmural drainage) or via the papilla
(transpapillary drainage). Both approaches, which usually require the insertion of one or more
plastic stents , have success rates of 70–87% and complication rates of 11–34% [10, 11].
Recently, endoscopic ultrasound (EUS)-guided transmural drainage (EUS-TD) has
been widely used to manage pancreatic pseudocysts, and its applications have been extended
gradually with the development of more innovative techniques and devices. Several reports
have indicated the feasibility of EUS-guided drainage of pancreatic fistulae and stasis of
pancreatic juice caused by a pancreatic duct stricture after pancreatic resection [12, 13].
However, no detailed reports are available comparing EUS-TD and percutaneous drainage of a
pancreatic fistula after pancreatic resection. To examine the utility and efficacy of EUS-TD, we
report six consecutive successful pancreatic fistula and pancreatic duct dilatation cases treated
by EUS-TD through the gastrointestinal tract and compare the outcomes with those of cases
treated by conventional percutaneous drainage.
Patients and methods
In total, 262 patients underwent surgery involving pancreatic resection at our hospital from
April, 2005 to March, 2010. A total of 172 patients (65%) did not have POPF and did not
undergo additional treatment. Ninety patients (34%) developed POPF and required additional
interventional treatment because they had symptoms such as fever and abdominal pain.
Sixty-six patients have been cured by conservative therapies, while 24 have not since a convex
array echo endoscope was introduced to our institute in April 2006. When POPFs were visible
by EUS, EUS-TD was the first choice for their treatment. Percutaneous drainage was the
second choice for treatment of refractory POPFs with symptoms or if they were not visible by
EUS. As a result, POPFs in five patients (2.1%) and dilatation of the main pancreatic duct
(MPD) caused by a stricture of the anastomosis in one, were detected by EUS and treated by
EUS-TD, and patients with a POPF not visible by EUS were treated with percutaneous
drainage (18 cases, 6.8%) or with a surgical drain followed by primary surgery (66 cases, 25%)
for the duration above.
In the six patients treated with EUS-TD (Table 1), initial surgical indications were
pancreatic carcinoma in three, bile duct carcinoma in two, and ampullary carcinoma in one.
Pancreatoduodenectomy had been performed in three cases; hepatopancreatoduodenectomy, in
two; and distal pancreatectomy, in one. After surgery, five patients (cases 1–5) developed a
POPF, and one (case 6) developed dilatation of the MPD. Three patients (cases 1, 2, and 6)
experienced fever, abdominal pain, or general