The endoscopic management of postoperative pancreatic fistula

Details

Supervisors

Deprez, Pierre

Faculty

Faculté de médecine et médecine dentaire

Degree label

Master [180] en médecine

Abstract

Introduction and aim. A postoperative pancreatic fistula (POPF) is one of the most prevalent clinically relevant complications after partial pancreatic resections. Endoscopic approaches have been proven successful, but the literature is scarce on the best route of drainage. Our study aimed at comparing efficacy and safety of transpapillary (ERCP based) and transmural (EUS guided) endoscopic treatment of POPFs occurring after distal pancreatectomies. Methods. We designed an observational and analytical retrospective cohort study on all patients (173) who underwent a distal pancreatectomy in our institution since 2000. The primary endpoint was the clinical success of endoscopic treatment defined as a complete resolution of POPF discharge and/or fluid collection (PFC) size decrease to < 2cm, with association of symptoms resolution, without the need for percutaneous drainage or surgery. Secondary endpoints were technical success (feasibility and efficacy of stent placement), complication rate of endoscopic procedures, and reintervention rate. Categorical variables were compared using χ² test. Normally distributed continuous variables were analyzed by Student t-test and non-normally distributed variables by the Mann-Whitney U-test. Patients were divided in 3 groups (ERCP only, EUS drainage only, both EUS and ERCP). Results. Out of 173 surgical patients, 58 (33,5%) developed POPF grade B and C and were treated by endoscopy. Rate of fistula was not correlated to surgery type (+-splenectomy, body and tail resection or solely tail, enucleation, isthmectomy, combined with other organ resections), neither to indication for surgery (malignancy, trauma, pancreatitis). Fistulas were more severe in older patients (p=0.043). Patients were treated by ERCP alone (n=31, 53.4%), EUS alone (n=13, 22.4%) or both procedures (n=14, 24.1%). There was a significant shift from ERCP alone (100% of cases between 2000-2005) to EUS alone and combined with ERCP (23% 2006-2010, and 48% 2011-2016). Technical success rates were similar in all groups (87-100-88%). Clinical success in patients treated by ERCP only was 64,5% (20/31) and as high as 96,3% (26/27) in patients in whom EUS was performed at any points during endoscopic treatment (p=0,003). The overall re-intervention rate was 44.8%, significantly lower when EUS was part of the treatments (20 and 23% vs. 55%, p<0.05). The complication rates related to ERCP and EUS procedures were respectively 9,5% (7/75) and 17% (6/35), p=0.237, with a decrease to only 2 AE in the last 5 years. Conclusions. Endoscopic treatment was highly successful in treating POPF after distal pancreatectomy, with a significantly better clinical success rate of EUS compared with ERCP, resulting in less reinterventions needed. We therefore suggest considering EUS as a primary approach, reserving ERCP for cases with pancreatic ductal strictures or inaccessible post-operative collections or fistulas.