Treatment of pancreaticoportal fistula by endosonography-guided rendezvous

Pancreatic fistula may occur as a complication of chronic pancreatitis [1] [2] [3]. However, a communicating fistula between the pancreatic ductal system and the portal vein is a rare and difficult-to-treat complication [4].

We present the first report of endoscopic ultrasound (EUS)-guided main pancreatic duct rendezvous treatment of a symptomatic case of pancreaticoportal fistula. The case was complicated by a partial portal vein thrombosis, related to a pancreatic pseudocyst from chronic pancreatitis.

A 69-year-old man presented with abdominal pain and weight loss during the previous 6 months. Laboratory tests revealed anemia (hemoglobin 7.7 g/dL) an increased amylase (7759 U/L) and an albumin of 3.4 g/L. Clinical history and abdominal magnetic resonance imaging (MRI) led to a diagnosis of pancreatic pseudocyst related to underlying alcoholic chronic pancreatitis. The MRI further showed a dilatation of the portal vein related to partial thrombosis ([Fig. 1]).

Fig. 1 A 69-year-old man underwent magnetic resonance imaging (MRI) 5 months after the onset of abdominal pain and weight loss. The MRI images showed portal vein thrombosis associated with increased caliber and parietal post-contrast enhancement: a, b coronal T2-weighted; c magnetic resonance cholangiography (MRC); d, e portal phase, post-gadolinium, fat-suppressed, T1-weighted; f late phase, post-gadolinium, fat-suppressed, T1-weighted. The pancreatic–portal communication, probably related to the pancreatic head pseudocyst is seen in part a (black arrows). The portal vein thrombus (white arrows, a – c) appears hyperintense on the T2-weighted and MRC images, most likely because of liquefaction caused by pancreatic juice. Lack of enhancement of the portal vein caused by thrombosis is shown on post-contrast T1-weighted images (white arrows, d – f), and parietal portal vein enhancement, probably related to inflammation, can be better seen on the late post-contrast phase image (f). The pancreatic head pseudocyst (*) is seen in parts b, c, and e. The dilated main pancreatic duct (arrowhead) is seen better in parts b and c. The normal biliary tree and gallbladder can be seen in part c, partially superimposed by portal vein thrombosis.

We performed an endoscopic retrograde pancreatography (ERP) that revealed a cystic collection in the head of the pancreas with stenosis and dilatation of the main pancreatic duct and secondary ducts. We were unable to pass a guidewire through the pancreatic duct stricture ([Fig. 2]). However, it was passed through a pancreaticoportal fistula, and the portal vein was visualized immediately after contrast injection.

Fig. 2 Endoscopic retrograde pancreatography (ERP) via the major duodenal papilla shows: a a pancreatic cystic collection with stenosis and dilatation of the main pancreatic duct and secondary ducts; b the guidewire passing into a pancreaticoportal fistula.

We then attempted an EUS-guided rendezvous maneuver. We accessed the main pancreatic duct through the stomach with a 19G needle, obtained pancreatography, and passed a 0.035-inch guidewire along the main duct through the minor duodenal papilla into the duodenum ([Fig. 3]). With the duodenoscope it was possible to grasp the guidewire and reposition it in the tail of the pancreas. We finally introduced a fully covered biliary self-expandable metallic stent (8 cm × 10 mm) across the pancreaticoportal fistula and the main pancreatic duct stenosis ([Fig. 4]).

Fig. 3 a Endoscopic ultrasound (EUS) shows the 19G needle inside the main pancreatic duct. b EUS-guided pancreatography and the insertion of the guidewire. c Passage of the guidewire through the minor duodenal papilla.

Fig. 4 a Endoscopic view of the guidewire exiting the minor duodenal papilla. b Fluoroscopy shows insertion of the fully covered self-expanding metal stent (SEMS). c, d Follow-up magnetic resonance imaging (MRI) after 1 month shows the SEMS inside the main pancreatic duct (white arrow), and persistence of portal vein thrombosis but with a marked decrease in the caliber of the portal vein (arrowheads).

Treatment of pancreaticoportal fistula by endosonography-guided rendezvous.

Reported treatments for this condition range from conservative medical management to some variation of pancreatectomy [5]. Because of the rarity of the condition, there is a clear need for individualized treatment. In our patient, the insertion of the fully covered self-expandable metallic stent led to marked clinical improvement, reduction of serum amylase (389 U/L), and improvement of the abnormalities visible on MRI; these improvements were found to be persistent at 6-month follow-up.

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• References

• 1 Van Steenbergen W, Ponette E. Pancreaticoportal fistula: a rare complication of chronic pancreatitis. Gastrointest Radiol 1990; 15: 299-300
• 2 Hastier P, Buckley MJ, Dumas R et al. Pancreaticoportal fistula after endoscopic cystogastrostomy in chronic calcifying pancreatitis. Pancreas 1998; 17: 208-210
• 3 Chang LH, Francoeur L, Schweiger F. Pancreaticoportal fistula in association with antiphospholipid syndrome presenting as ascites and portal system thrombosis. Can J Gastroenterol 2002; 16: 601-605
• 4 Itoi T, Kasuya K, Sofuni A et al. Endoscopic ultrasonography-guided pancreatic duct access: techniques and literature review of pancreatography, transmural drainage and rendezvous techniques. Dig Endosc 2013; 25: 241-252
• 5 Ng TS, Rochefort H, Czaplicki C et al. Massive pancreatic pseudocyst with portal vein fistula: case report and proposed treatment algorithm. Pancreatology 2015; 15: 88-93