F. Pugliese

Pancreatic Leaks and Fistulae: An Endoscopy-Oriented Classification

BackgroundPancreatic leaks occur as a complication of upper gastrointestinal surgery, acute pancreatitis, or abdominal trauma. Pancreatic fistulas and leaks are primarily managed conservatively. Overall, conservative measures are successful in more than half of cases. Whenever conservative treatment is not efficient, surgery is usually considered the treatment of choice. Nowadays however, endoscopic treatment is being increasingly considered and employed in many cases, as a surgery sparing intervention.AimTo introduce a classification of pancreatic fistulas according to the location of the leak and ductal anatomy and finally propose the best suited endoscopic method to treat the leak according to current literature.MethodsWe performed an extensive review of the literature on pancreatic fistulae and leaks.ResultsIn this paper, we review the various types of leaks and propose a novel endoscopic classification of pancreatic fistulas in order to standardize and improve endoscopic treatment.ConclusionsA proper and precise diagnosis should be made before embarking on endoscopic treatment for pancreatic leaks in order to obtain prime therapeutic results. A multidisciplinary team of interventional endoscopists, pancreatic surgeons, and interventional radiologists is best suited to care for these patients.

Endoscopic multiple metal stenting for the treatment of enteral leaks near the biliary orifice: A novel effective rescue procedure.

Between April 2013 and October 2015, 6 patients developed periampullary duodenal or jejunal/biliary leaks after major abdominal surgery. In all patients, percutaneous drainage of the collection or re-operation with primary surgical repair was attempted at first but failed. A fully covered enteral metal stent was placed in all patients to seal the leak. Subsequently, we cannulated the common bile duct and, in some cases, and the main pancreatic duct inserting hydrophilic guidewires through the stent after dilating the stent mesh with a dilatation balloon or breaking the meshes with Argon Plasma Beam. Finally, we inserted a fully covered biliary metal stent to drain the bile into the lumen of the enteral stent. In cases of normal proximal upper gastrointestinal anatomy, a pancreatic plastic stent was also inserted. Oral food intake was initiated when the abdominal drain outflow stopped completely. Stent removal was scheduled four to eight weeks later after a CT scan to confirm the complete healing of the fistula and the absence of any perilesional residual fluid collection. The leak resolved in five patients. One patient died two days after the procedure due to severe, pre-existing, sepsis. The stents were removed endoscopically in four weeks in four patients. In one patient we experienced stent migration causing small bowel obstruction. In this case, the stents were removed surgically. Four patients are still alive today. They are still under follow-up and doing well. Bilio-enteral fully covered metal stenting with or without pancreatic stenting was feasible, safe and effective in treating postoperative enteral leaks near the biliopancreatic orifice in our small series. This minimally invasive procedure can be implemented in selected patients as a rescue procedure to repair these challenging leaks.

Colo-rectal endoscopic full-thickness resection (EFTR) with the over-the-scope device (FTRD®): A multicenter Italian experience

BACKGROUND AND AIM Endoscopic full-thickness resection(EFTR) with FTRD® in colo-rectum may be useful for several indications.The aim was to assess its efficacy and safety. MATERIAL AND METHODS In this retrospective multicenter study 114 patients were screened; 110 (61M/49F, mean age 68 ± 11 years, range 20-90) underwent EFTR using FTRD®. Indications were:residual/recurrent adenoma (39), incomplete resection at histology (R1 resection) (26), non-lifting lesion (12), adenoma involving the appendix (2) or diverticulum (2), subepithelial lesions(10), suspected T1 carcinoma (16), diagnostic resection (3). Technical success (TS: lesion reached and resected), R0 resection (negative lateral and deep margins),EFTR rate(all layers documented in the specimen) and safety have been evaluated. RESULTS TS was achieved in 94.4% of cases. EFTR was achieved in 91% with lateral and deep R0 resection in 90% and 92%. Mean size of specimens was 20 mm (range 6-42). In residual/recurrent adenomas, final analysis revealed: low-risk T1 (11), adenoma with low-grade dysplasia (LGD) (24) and high-grade dysplasia (HGD) (3), scar tissue (1). Histology reports of R1 resections were: adenoma with LGD (6), with HGD (1), low-risk (6) and high-risk (1) T1, scar tissue (12). Non-lifting lesions were diagnosed as: adenoma with HGD (3), low-risk (7) and high risk (2) T1. Adverse clinical events occurred in 12 patients (11%),while adverse technical events in11%. Three-months follow-up was available in 100 cases and residual disease was evident in only seven patients. CONCLUSIONS EFTR using FTRD® seems to be a feasible, effective and safe technique for treating selected colo-rectal lesions. Comparative prospective studies are needed to confirm these promising results.

An unusual case of impacted biliary stone

The incidence of biliary stones is higher in the female sex [1, 2]. Common bile duct (CBD) stones are the most common cause of acute biliary pancreatitis (ABP) [3]. We report the case of a 39-year-old woman with ABP. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with an initial approach to the minor papilla, which looked like the major papilla. During ERCP we observed an impacted biliary stone in the papilla (▶Fig. 1; ▶Video1). Pre-cut was performed resulting in spontaneous stone expulsion, but it was not possible to gain access to the CBD. The contrast medium injection revealed a dilated Santorini duct originating from the cut papilla. The junction between the Santorini and the Wirsung duct was far from the minor papilla, in the 3 rd duodenal portion, with an abnormal biliopancreatic junction, and an uncommon intramural channel > 15mm (▶Fig. 2). After pancreatography, a wire was advanced into the Santorini duct, through the Wirsung duct, to the duodenum, across the major papilla. After the “inverted rendezvous,” a septotomy was performed, which enabled CBD access, and then endoscopic biliary sphincterotomy (EBS) was performed. The cholangiography showed a 10mm diameter CBD with multiple fragmented stones in the distal portion. The fragments were extracted using a Dormia basket, and a 7 Fr ×5 cm pancreatic plastic stent was placed for the prevention of post-ERCP acute pancreatitis (▶Video1).

New endoscopic technique for uncontrollable bilious vomiting after gastrojejunal surgical bypass

Gastrojejunal Billroth II or single Rouxen-Y reconstructions that create a defunctionalized loop, are usually performed to treat patients with unresectable periampullary tumors [1, 2]. The main adverse effect is bile reflux [3, 4], with irritation of the gastric mucosa, that can generally be controlled with prokinetic drugs [1–4]. However, if the symptoms are severe, a redo surgery is the only available option described in the literature [1–4]. A 70 year-old man presented with copious vomiting of bile associated with inability to eat due to severe acute alkaline gastritis. Because of an inoperable pancreatic head tumor (with liver metastases), the patient had undergone biliojejunal and gastrojejunal surgical bypasses on a single Roux-en-Y defunctionalized loop 1month earlier. (The surgeons had begun to create a Roux-en-Y reconstruction. However during the operation they had decided to use the biliary loop for the gastrojejunal anastomosis also. Thus they had created a single isolated Roux-en-Y loop and functionally a Billroth II reconstruction.) From the earliest postoperative days the patient began to vomit bile increasingly because of gastroparesis linked to severe acute alkaline injury of the gastric mucosa. In agreement with the surgeons, we decided to propose a new endoscopic technique to the patient for palliation of the clinical problem. First, we placed a 7-Fr nasojejunal tube in the efferent part of the Roux-en-Y loop under both endoscopic and fluoroscopic view so that we could identify the efferent loop using endoscopic ultrasound. Then, we introduced a linear echoendoscope (EG-3870 UTK; Pentax, Hamburg, Germany) into the afferent part of the loop (containing the biliary anastomosis). After dilating the efferent part (the portion after the gastrojejunal anastomosis) with physiological solution, we were able to locate it endosonographically. We failed to perform an endoscopic enteral bypass with our previously described usual technique (using a cystoenterostome and a fully covered lumen-apposing metal stent [LAMS], 16mm×20mm) [5] having lost the correct position because of loose intestinal contact caused by ascites. At the end of this first attempt, we placed some endoclips to close the intestinal perforation. The following day we used the Hot Axios Stent and Electrocautery Enhanced Delivery System (Boston Scientific, Marlborough, Massachusetts, USA) to pass from the afferent to the efferent portion and we created a fixed new bridge between them using a LAMS (diameter 15–24mm, length 10mm) (▶Video 1). The patient had an immediate resolution of symptoms and a prompt improvement in terms of quality of life with 3 months of follow-up. This new endoscopic technique was used as a rescue therapy in a patient with low life expectancy and poor general condition in order to avoid a surgical re-operation. We have begun to verify this first result with a prospective study in selected patients.

Triple stenting to treat a complete Wirsung-to-jejunum anastomotic leak after pancreaticoduodenectomy

Dehiscences of pancreatic–jejunal anastomoses are the commonest complication, and one of the worst, after duodenopancreatectomies [1]. The treatment is generally re-do surgery, with a residual pancreatectomy being performed in the most severe cases [1]. Endotherapy is generally not considered as an alternative in patients with complete and/or complex leaks [1]. However, endoscopic treatment of postoperative pancreatic fistulas has already been described [2– 4]. A 58-year-old patient presented with obstructive jaundice due to a distal cholangiocarcinoma. The patient underwent duodenopancreatectomy (Whipple–Child procedure) with Wirsung-tojejunum anastomosis. On the 10th postoperative day, he developed a sudden onset of fever associated with bilious vomiting and a leukocytosis. An abdominal computed tomography (CT) scan was performed, which showed a pelvic fluid collection most likely due to pancreatic anastomotic dehiscence. The fluid collection was immediately drained percutaneously with output of 700mL per day. From measurements of amylase levels in the drainage fluid, we suspected the presence of a high-outflow pancreatic fistula. Therefore, we decided to perform an endoscopic retrograde cholangiopancreatography (ERCP) to confirm the diagnosis. At the endoscopy, performed using a pediatric colonoscope (EC 3490 LK; Pentax), which reached to the distal edge of the afferent jejunal loop with the aid of fluoroscopy, we found a complete dehiscence of the pancreatic anastomosis with a wide defect in the intestinal wall (the pancreatic stump and surgical drain were visible). The surgical pancreatic stent (inserted at the operation) was still in situ. We decided to treat this wide defect by adapting our previously reported technique of triple stenting [4] for the present case. Firstly, we replaced the surgical stent with a 12-cm long, 7-Fr plastic stent (CHBSO 7-5; Cook Medical) using a hydrophilic curved guidewire (Delta Wire; Cook Medical). We also placed an enteral 20-mm×8-cm fully covered selfexpandable metal stent (FCSEMS; Niti-S; EuroMedical) in the distal part of the afferent jejunal loop to close the defect in the wall. Subsequently, we searched the biliary anastomosis through the meshes of the jejunal SEMS using the Delta Wire and placed a biliary FCSEMS (10mm×4cm; WallFlex; Boston Scientific) through the biliary anastomosis with the proximal edge inside the jejunal stent to stabilize the position of the enteral stent. Finally, we looked for the proximal edge of the plastic pancreatic stent that was between the jejunal SEMS and the jejunal wall. Once we had found the plastic stent, we opened the jejunal SEMS using argon plasma coagulation (APC) and pulled the proximal edge of the plastic stent inside the jejunal stent. We decided to replace the plastic pancreatic stent with another FCSEMS (6mm×8cm; WallFlex) to obtain the best stabilization of the prosthetic complex (▶Video1). The fistula output reduced to zero over 3 days and we removed the percutaneous drain after a follow-up abdominal CT scan had been performed. We removed the prosthetic complex 5 weeks later, having confirmed complete healing of the surgical anastomosis.

Endotherapy for bile leaks from isolated ducts after hepatic resection: A long awaited challenge

BACKGROUND Bile leakage is a common complication after hepatic resection [1-4] (Donadon et al., 2016; Dechene et al., 2014; Zimmitti et al., 2013; Yabe et al., 2016). Endotherapy is the treatment of choice for this complication except for bile leaks originating from isolated ducts; a condition resembling the post laparoscopic cholecystectomy Strasberg type C lesions [5-9] (Lillemo et al., 2000; Gupta and Chandra, 2011; Park et al., 2005; Colovic, 2009; Mutignani et al., 2002). In such cases, surgical repair is complex, often of uncertain result and with a high morbidity and mortality [1] (Donadon et al., 2016). On the other hand, percutaneous interventions (i.e. plugging the isolated duct with glue) are technically difficult and risky [7,8] (Park et al., 2005; Colovic, 2009). Endoscopy, thus far, was not considered amongst treatment options. That is because the isolated duct cannot be opacified during cholangiography and is not accessible with the usual endoscopic methods [5,6] (Lillemo et al., 2000; Gupta and Chandra, 2011). METHODS Considering the pathophysiology of this type of bile leaks, it is possible to change the pressure gradient endoscopically in order to direct bile flow from the isolated duct towards the duodenal lumen, thus creating an internal biliary fistula to restore bile flow. In order to achieve this goal, we have to perforate the biliary tree into the abdomen. The key element of endoscopic treatment is to create a direct connection between the abdominal cavity and the duodenal lumen by-passing the residual biliary tree with a new technique fully explained in the paper. Our case series (from 2011 to 2016) consists of 13 patients (eight male, five female, mean age 58 years) with fistulas from isolated ducts after various types of hepatic resection. RESULTS We performed sphincterotomy and placed a biliary stent with the proximal edge inside the intra-abdominal bile collection in 11 patients (eight biliary fully-covered self-expandable metal stents; three plastic stents). In the remaining two patients we successfully cannulated the involved isolated biliary duct and we placed a bridging stent (one fully covered self-expandable metal stent; one plastic stent). Technical and clinical success (considered as fistula healing) was achieved in all 13 patients (mean fistula healing time was four days). Biliary stents were removed three to six months after atrophy of the involved duct in nine cases. In two patients the stent is still in situ. Two patients died with stent in situ due to advanced cancer at 8 and 42 months respectively. Mean follow up was 18 months (range: 8-42 months). CONCLUSIONS The described endoscopic treatment is innovative, safe and effective. It is applicable in tertiary level endoscopic centers and requires considerable expertise. This minimally invasive procedure can increase the rate of fistula healing and will eventually reduce the need for more aggressive and risky surgical procedures.

Endoscopic Stenting With the Over-The-Scope Technique: Our Experience With 11 Consecutive Patients

Background: Endoscopic stenting is widely used to manage benign and malignant strictures, postoperative stenoses, or anastomotic leaks and fistulas. Materials and Methods: However, Over the Wire delivery systems are generally short and quite stiff, and therefore, cannot reach distal parts of the gastrointestinal tract or cross severely angulated strictures. In such cases, we used the Over-the-Scope stenting (OTSS) technique to deliver and deploy endoscopically large-bore fully covered stents. We present herein a series of 11 patients treated with the OTSS technique for a variety of indications. To our knowledge, this is the largest series of OTSS cases published. Results: The stents were correctly deployed in 10 cases. In one case, the stent was dislocated during scope withdrawal and Through the Scope stenting was performed with a smaller diameter uncovered stent instead. Predilation of the stricture was necessary in 5 patients. Clinical success was achieved in all patients. Conclusions: Our results encourage the use of the OTSS technique in cases where standard Over the Wire delivery systems of large-bore stents cannot reach or cross distal or tortuous strictures. The technique can also be used to reinsert migrated stents or misplaced braided-suture release mechanism (Ultraflex) stents.