Post written by Saeed Ali, MD, from AdventHealth Orlando, Orlando, Florida, USA, and Brian Boulay, MD, MPH, from the Division of Gastroenterology and Hepatology, Department of Medicine, University of Illinois Hospital and Health Sciences Center, Chicago, Illinois, USA.

This is an interesting case of a 67-year-old man who developed acute necrotizing pancreatitis followed by a 19-cm pseudocyst with a mass effect on the stomach. He was initially treated at another institute with antibiotics and percutaneous drain placement. Although this was successful in treating fluid collection, he visited our clinic with a pancreaticocutaneous fistula draining 100 to 150 mL daily.

Our initial ERCP was unsuccessful, as the major papilla was located on the rim of a diverticulum. An EUS rendezvous maneuver was attempted after puncture of the upstream pancreatic duct (PD) via a transgastric approach. A 19-gauge access needle (Cook Medical, Bloomington, Ind, USA) was used to puncture the PD in the body.

After contrast was injected, a pancreatogram showed an abrupt cutoff of the PD in the mid-body, confirming a complete PD disruption. A 0.035-inch wire failed to pass through the disruption.

Pancreaticogastrostomy or pancreatic tail resection was considered, but given the morbidity associated with those approaches, a hybrid procedure using endoscopic and interventional radiology (IR) expertise simultaneously was planned. The percutaneous pigtail drain was identified within the fistula tract with the use of the linear array echoendoscope. Contrast injection through the drain showed a 19-mm residual collection with fistula to the main PD in the body and tail.

The percutaneous drain was removed over 2 stiff hydrophilic coated guidewires (GLIDEWIRE; Terumo, Tokyo, Japan). A Fogarty balloon catheter (Edwards Lifesciences, Irvine, Calif, USA) and an endovascular snare catheter (Merit, South Jordan, Utah, USA) were advanced over both wires into the residual peripancreatic collection. The balloon was inflated as a target for needle puncture.

Under endosonographic guidance with a 19-gauge access needle, the stomach wall and balloon within the fistula were punctured. A long 0.035-inch stiff guidewire (Jagwire; Boston Scientific, Marlborough, Mass, USA) was inserted through the needle into the fistula cavity and captured by the IR staff using the snare and pulled out through the abdominal wall in a rendezvous style.

A 6F flexor sheath (Cook Medical) was advanced over the wire and through the gastric wall to the gastric lumen, and a second 0.035-inch stiff guidewire (Jagwire) was advanced through the sheath and snared by the endoscopist for through-and-through access. The transgastric tract was dilated with an 8-mm balloon dilator, and two 4-cm, 7F double-pigtail stents were then placed into the fistula cavity through the newly dilated tract over each of the 2 wires.  

Over the next 6 months, the patient reported no further percutaneous drainage. These stents will remain there indefinitely.

Disconnected PD syndrome with a resulting pancreaticocutaneous fistula is a challenging condition but can be managed endoscopically in most cases. This is a unique case where IR previously drained the collection, leading to absence of an identifiable target for direct endoscopic drainage, requiring a hybrid procedure with IR to help identify the collection for successful conversion of the external-to-internal drainage.

Although the lumen-apposing metal stent revolution has provided therapeutic endoscopists with plenty of experience with transluminal drainage of large pancreatic fluid collections, directing drainage into the stomach is much more difficult in the case of a small target (such as a collapsed cavity with a pigtail drain). Coordination between IR staff and therapeutic endoscopists (“dual-modality drainage”) to provide a new transgastric tract has been described but is not a commonly used technique.

In this case, our interventional radiologists provided an obvious target with a balloon catheter to allow us to access the tract. By creating a new transgastric tract, we invited the flow of pancreatic juice to the stomach, instead of out through the drain.

Graphic illustration of the main steps of the endoscopic techniques used in this case.

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