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DOI: 10.1055/s-0042-102448
Treatment of pancreaticoportal fistula by endosonography-guided rendezvous
Publikationsverlauf
Publikationsdatum:
14. März 2016 (online)
![](https://www.thieme-connect.de/media/endoscopy/2016S01/lookinside/thumbnails/13644_10-1055-s-0042-102448-1.jpg)
Pancreatic fistula may occur as a complication of chronic pancreatitis [1] [2] [3]. However, a communicating fistula between the pancreatic ductal system and the portal vein is a rare and difficult-to-treat complication [4].
We present the first report of endoscopic ultrasound (EUS)-guided main pancreatic duct rendezvous treatment of a symptomatic case of pancreaticoportal fistula. The case was complicated by a partial portal vein thrombosis, related to a pancreatic pseudocyst from chronic pancreatitis.
A 69-year-old man presented with abdominal pain and weight loss during the previous 6 months. Laboratory tests revealed anemia (hemoglobin 7.7 g/dL) an increased amylase (7759 U/L) and an albumin of 3.4 g/L. Clinical history and abdominal magnetic resonance imaging (MRI) led to a diagnosis of pancreatic pseudocyst related to underlying alcoholic chronic pancreatitis. The MRI further showed a dilatation of the portal vein related to partial thrombosis ([Fig. 1]).
![](https://www.thieme-connect.de/media/endoscopy/2016S01/thumbnails/10-1055-s-0042-102448-i13644cl1.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
We performed an endoscopic retrograde pancreatography (ERP) that revealed a cystic collection in the head of the pancreas with stenosis and dilatation of the main pancreatic duct and secondary ducts. We were unable to pass a guidewire through the pancreatic duct stricture ([Fig. 2]). However, it was passed through a pancreaticoportal fistula, and the portal vein was visualized immediately after contrast injection.
![](https://www.thieme-connect.de/media/endoscopy/2016S01/thumbnails/10-1055-s-0042-102448-i13644cl2.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
We then attempted an EUS-guided rendezvous maneuver. We accessed the main pancreatic duct through the stomach with a 19G needle, obtained pancreatography, and passed a 0.035-inch guidewire along the main duct through the minor duodenal papilla into the duodenum ([Fig. 3]). With the duodenoscope it was possible to grasp the guidewire and reposition it in the tail of the pancreas. We finally introduced a fully covered biliary self-expandable metallic stent (8 cm × 10 mm) across the pancreaticoportal fistula and the main pancreatic duct stenosis ([Fig. 4]).
![](https://www.thieme-connect.de/media/endoscopy/2016S01/thumbnails/10-1055-s-0042-102448-i13644cl3.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
![](https://www.thieme-connect.de/media/endoscopy/2016S01/thumbnails/10-1055-s-0042-102448-i13644cl4.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Qualität:
Reported treatments for this condition range from conservative medical management to some variation of pancreatectomy [5]. Because of the rarity of the condition, there is a clear need for individualized treatment. In our patient, the insertion of the fully covered self-expandable metallic stent led to marked clinical improvement, reduction of serum amylase (389 U/L), and improvement of the abnormalities visible on MRI; these improvements were found to be persistent at 6-month follow-up.
Endoscopy_UCTN_Code_TTT_1AS_2AD
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References
- 1 Van Steenbergen W, Ponette E. Pancreaticoportal fistula: a rare complication of chronic pancreatitis. Gastrointest Radiol 1990; 15: 299-300
- 2 Hastier P, Buckley MJ, Dumas R et al. Pancreaticoportal fistula after endoscopic cystogastrostomy in chronic calcifying pancreatitis. Pancreas 1998; 17: 208-210
- 3 Chang LH, Francoeur L, Schweiger F. Pancreaticoportal fistula in association with antiphospholipid syndrome presenting as ascites and portal system thrombosis. Can J Gastroenterol 2002; 16: 601-605
- 4 Itoi T, Kasuya K, Sofuni A et al. Endoscopic ultrasonography-guided pancreatic duct access: techniques and literature review of pancreatography, transmural drainage and rendezvous techniques. Dig Endosc 2013; 25: 241-252
- 5 Ng TS, Rochefort H, Czaplicki C et al. Massive pancreatic pseudocyst with portal vein fistula: case report and proposed treatment algorithm. Pancreatology 2015; 15: 88-93