Costamagna G, Mutignani M, Ingrosso M, Vamvakousis V, Alevras P, Manta R, Perri V
Digestive Endoscopy Unit, Dept. of Surgery, Catholic University, Rome, Italy.
Endoscopy. 2001 Apr;33(4):317-22. doi: 10.1055/s-2001-13695.
External pancreatic fistulas (EPFs) are managed primarily by conservative treatment with a success rate of 40-90%. Failures of conservative therapy have traditionally been dealt with using surgery; however, major morbidity and mortality are associated with operative treatment. The aim of this study was to evaluate the feasibility and effectiveness of endoscopic treatment in the closure of EPF.
A total of 16 consecutive patients with EPF (12 men, four women; median age 50, range 21-66) underwent an attempt at endoscopic management after failure of conservative therapy. Four patients had chronic pancreatitis. All patients had EPFs occurring after open abdominal surgery. The mean interval between the onset of the fistula and our intervention was 108 days (range 27-365 days). The mean output volume of the fistula was 205 ml/d (range 50-600 ml/ d). The aim of treatment was to lower the pancreatic duct pressure and to bypass the ductal disruption by placement of drains and/or stents to induce fistula healing.
In all, 13 biliary and nine pancreatic sphincterotomies were performed in order to gain access to the pancreatic duct. Access through the minor papilla was required in one patient. Complete visualization of the main pancreatic duct as well as of the fistulous tract was obtained in 12 patients (75%). Treatment consisted of placement of a nasal pancreatic drain (NPD) across the pancreaticojejunal anastomosis in one patient after duodenopancreatectomy. In 11 of the remaining 15 patients (73%) a NPD could be placed in the pancreatic duct across the ductal leakage (n = 9) or nearby (n = 2). One patient died 24 hours after endoscopic treatment from severe sepsis and massive pulmonary embolism. Endoscopic drainage was effective in healing the EPF in all patients in whom NPDs had been successfully placed, except one. The fistula in this patient healed completely after insertion of an 8.5-Fr pancreatic stent. The mean interval between endoscopic treatment and fistula closure was 8.8 days (range 2-33 days). No complications related to the endoscopic treatment were recorded in this series. In the 12 successfully treated patients, fistulas did not recur in any of the 11 surviving patients after a mean follow-up of 24.7 months (range 3-63 months).
Endoscopic pancreatic drainage, when feasible, is safe and effective for EPF and should be considered as a first-line therapy when EPFs do not respond to conservative therapy.
胰外瘘（EPF）主要通过保守治疗，成功率为40% - 90%。传统上，保守治疗失败后采用手术治疗；然而，手术治疗存在较高的发病率和死亡率。本研究旨在评估内镜治疗在闭合EPF中的可行性和有效性。
16例连续性EPF患者（男12例，女4例；中位年龄50岁，范围21 - 66岁）在保守治疗失败后接受了内镜治疗尝试。4例患者患有慢性胰腺炎。所有患者的EPF均发生于开腹手术后。瘘管形成至我们进行干预的平均间隔时间为108天（范围27 - 365天）。瘘管的平均引流量为205 ml/d（范围50 - 600 ml/d）。治疗目的是通过放置引流管和/或支架降低胰管压力并绕过导管破裂处，以促进瘘管愈合。
为进入胰管，共进行了13次胆管括约肌切开术和9次胰管括约肌切开术。1例患者需要通过副乳头进入。12例患者（75%）实现了主胰管及瘘管的完全可视化。1例十二指肠胰头切除术后患者，在内镜下于胰肠吻合口处放置了鼻胰引流管（NPD）。其余15例患者中的11例（73%），可在内镜下于胰管内导管漏口处（9例）或其附近（2例）放置NPD。1例患者在内镜治疗后24小时因严重脓毒症和大面积肺栓塞死亡。除1例患者外，成功放置NPD的所有患者内镜引流均有效促进了EPF愈合。该例患者在置入8.5 - Fr胰管支架后瘘管完全愈合。内镜治疗至瘘管闭合的平均间隔时间为8.8天（范围2 - 33天）。本系列未记录与内镜治疗相关的并发症。12例成功治疗的患者中，11例存活患者平均随访24.7个月（范围3 - 63个月），瘘管均未复发。
内镜下胰管引流在可行时，对EPF安全有效，当EPF对保守治疗无反应时，应考虑作为一线治疗方法。
