Combined interventions on pancreatic ducts with external fistulas

The present paper describes clinical observation of successful treatment of a patient with chronic calcifying pancreatitis complicated by an external pancreatic fistula. Abdominal surgery after laparotomy and cholecystectomy had to be limited to bursoomentostomy due to the bleeding tissues and severe blood loss. Combined endoscopic intervention through the external pancreatic fistula was used for the treatment. The performed interventions included stone extraction in Wirsung’s duct, dilation and stenting of the distal stricture of the pancreatic duct. The fistula closed, a pain-free period lasted for 3 years. Similar transfistula interventions were performed in 7 patients with chronic pancreatitis and external pancreatic fistulas, lithiasis in Wirsung's duct (n = 5) and pancreatic duct strictures (n = 6). A total of 17 procedures were performed, 7 of 8 fistulas were closed. Complications developed in 3 observations, no lethal outcome was registered.

Conclusion. Transfistula interventions in pancreatic ducts with combined X-ray guidance, oral and transfistula endoscopy can be used to remove stones, dilate strictures and restore natural passage of pancreatic secretions as an independent treatment or preparation for planned abdominal surgery.

1. Sazonov D.V., Pastuhov A.I., Lesnyak V.N., Semendyaeva M.I. Case history of endoscopic stanting in complex treatment of chronic pancreatitis. Journal of Clinical Practice. 2012; 1: 40–45. (In Russian)

2. Budzinskiy S.A., Shapovalianz S.G., Fedorov E.D., Mylnikov A.G., Bakaev Z.R., Bahtiozina D.V. Possibilities and limitations of retrograde transpapillary stenting of the main pancreatic duct in the treatment of chronic pancreatitis and its complications. Eksperimental’naya i Klinicheskaya Gastroenterologiya. 2014; 103 (3): 72–76. (In Russian)

3. Stepan E.V., Ermolov A.S., Rogal’ M.L., Teterin Yu.S. External pancreatic fistulas management. Pirogov Russian Journal of Surgery = Khirurgiya. Zurnal im. N.I. Pirogova. 2017; 3: 42–49. https://doi.org/10.17116/hirurgia2017342-49 (In Russian)

4. Butturini G., Daskalaki D., Molinari E., Scopelliti F., Casarotto A., Bassi C. Pancreatic fistula: definition and current problems. J. Hepatobiliary Pancreat. Surg. 2008; 15 (3): 247– 251. https://doi.org/10.1007/s00534-007-1301-y

5. Klinicheskie rekomendatsii. Chronicheskii pankreatit [Clinical guidelines. Chronic pancreatitis. Approved by the Ministry of Health of the Russian Federation]. 2020 (20.04.2021). ID: 273 (In Russian)

6. Shapovalyants S.G., Mylnikov A.G., Budzinskiy S.A., Shabrin A.V. Endoscopic stenting of the main pancreatic duct in pancreatic fistula patients in pancreatic fistula patients. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2012; 17 (2): 53–58. (In Russian)

7. Budzinskiy S.A., Shapoval’yants S.G., Fedorov E.D., Shabrin A.V. Endoscopic pancreatic stenting in pancreatic fistulas management. Pirogov Russian Journal of Surgery = Khirurgiya. Zurnal im. N.I. Pirogova. 2017; 2: 32–44. https://doi.org/10.17116/hirurgia2017232-44 (In Russian)

8. Dumonceau J.M., Delhaye M., Tringali A., Arvanitakis M., Sanchez-Yague A., Vaysse T., Aithal G.P., Anderloni A., Bruno M., Cantú P., Devière J., Domínguez-Muñoz J.E., Lekkerkerker S., Poley J.W., Ramchandani M., Reddy N., van Hooft J.E. Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2012; 44 (8): 784–800. https://doi.org/10.1055/s-0032-1309840

9. Morgan K.A., David B., Adams B. Management of internal and external pancreatic fistulas. Surg. Clin. N. Am. 2007; 87(6): 1503–1513. https://doi.org/10.1016/j.suc.2007.08.008

10. Avanesyan R.G. Obocnovanie kombinirovannogo minimalno invazivnogo khirurgicheskogo lecheniya vnutriprotokovoi gipertenzii pri khronicheskom pankreatite [Rationale for combined minimally invasive surgical treatment of intraductal pancreatic hypertension in chronic pancreatitis: dis. … doct. med. sci.]. Saint Petersburg, 2020. 339 р. (In Russian)

11. Prudkov M.I. Instrumentalnoe chresphistulnoe lechenie bolnych s konkrementami v zhelchnych putyach [Instrumental transfistula treatment of patients with calculi in the biliary tract: dis. … cand. med. sci.]. Sverdlovsk, 1984. 180 p. (In Russian)

12. Kovalevskii A.D., Prudkov M.I. Transfistula cholangioscopy: clarification of the diagnosis and antegrade removal of residual bile duct stones. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2022; 27 (3): 74–80. https://doi.org/ 10.16931/1995-5464.2022-3-74-80 (In Russian)

13.