EUS-GUIDED PANCREATIC RENDEZVOUS TO RESCUE FAILED ERCP FOR POSTOPERATIVE PANCREATIC FISTULAS (POPF) AFTER PANCREATICODUODENECTOMY

Background:
Clinically significant pancreatic fistulas after a Whipple occur in 25-30% patients and are associated with disease specific risk factors such as small pancreatic ducts and softer glands, patient related factors such as age, obesity, malnutrition and the surgical technique such as type of anastomosis and blood loss. They are diagnosed with drain amylase levels greater than 3 times the serum amylase. The mainstay of treatment is drainage – most commonly done percutaneously with a median median duration of drains for 30 and 40 days for Grades B and C fistulas. We present 3 cases who failed percutaneous drainage alone and conventional ERCP but were rescued with EUS pancreatic rendezvous.
Case and Results:
The first patient was a 56 year old male admitted 28 days post-Whipple despite 2 indwelling percutaneous drains with wound dehiscence and pancreatic juice leaking from his incisions and sepsis. Frank purulence was seen emerging at his pancreaticojejunostomy with inability to find the upstream pancreatic duct. Despite only a 1.5mm pancreatic duct at EUS, a successful renzvous was performed allowing placement of a 7 Fr pancreatic duct stent. After drain removal 16 days post procedure, he was taken for an ERCP Day 72 to remove his stent, but there was still a dehiscence, and an inabilty to cannulate the pancreatic duct requiring a second renzvous and then a longer dwell time for the stent for an additional 182 days. This allowed him to be stent free and without pancreatitis for a follow up of 33 months.
Three consecutive patients with a median age of 62, median BMI of 40, were included. They all had a soft gland and the median pancreatic duct pre-operatively was only 2.5mm. Also, 2 of the 3 patients had intraoperative stents placed. All patinets failed an attempted ERCP due to the large dehiscence at the pancreaticojejunostomy. They had a median of 2 drains for a median duration of 30 days prior to the EUS. Median pancreatic duct size on EUS was small at 2mm and we used 1 or 2 7Fr stents in all cases. Percutaneous drains were removed after a median of 20 days after the EUS and the median stent dwell time was 210 days. Median follow up was 33 months with no adverse events or recurrences.
Conclusion:
Postoperative pancreatic fistulas after a Whipple that are clinically severe (Grade B and C) may sometimes fail management with percutaneous drains alone. Conventional ERCP maybe difficult if there is a large dehiscence. EUS pancreatic rendezvous can help bridge these leaks but can be challenging due to the decompressed pancreatic duct but careful needle puncture and wire manipulation can allow access and reconnecting the disrupted duct to the jejunum. Median time to drain removal may be shortened in these situations. Further studies are needed to compare this approach to percutaneous drainage alone.