Transpapillary stenting for pancreaticocutaneous fistulas

Because transpapillary stents have been successfully placed to treat the ductal disruptions associated with pseudocysts, pancreatic ascites and pleural effusions, and pancreaticoenteric fistulas, we reviewed our experience with endoscopically placed prostheses in patients who had persistent pancreaticocutaneous fistulas but an otherwise intact duct. Nine patients who underwent endoscopic transpapillary stent placement for ongoing pancreaticocutaneous fistulas at our institution were retrospectively reviewed. Fistulas were present for a mean (+/-SEM) of 35 +/- 11 days and averaged 225 +/- 55 ml of output daily. Etiology of the fistulas included percutaneous pseudocyst drainage in four patients, pancreatic necrosis in two, complications of pancreatic surgery in two, and perforation of the duct of Santorini at the time of minor sphincterotomy in one. All patients had an otherwise intact duct at the time of endoscopic retrograde cholangiopancreatography. Six patients had transpapillary stents placed that did not bridge the area of leakage and three had prostheses placed across the ductal disruption. Eight of nine fistulas were successfully closed by means of this technique including five within 48 hours. There was one instance of stent migration and one patient developed prosthesis occlusion and an infected pseudocyst, which was treated with stent exchange. Stents were retrieved 10 to 14 days after fistula closure and no patient has had a recurrence at a median follow-up of 3 years. Transpapillary stents appear to effect closure of pancreaticocutaneous fistulas that fail to respond to conventional therapy.