Pancreatic leaks treated according to a new endoscopy-oriented classification: a tertiary-care Center experience

Aims Pancreatic leaks (PLs) are common complications following pancreatic surgery and acute pancreatitis. Advancements in interventional endoscopy have considerably changed their management, reducing the need for surgical intervention. The most widely used classification, the International Study Group of Pancreatic Fistulas (ISGPF) Classification, focuses on the clinical severity; in 2017 our group proposed an endoscopy-oriented classification that integrates anatomical and functional criteria, aiming to guide endoscopic treatment selection more effectively. We aimed to assess the clinical validity and utility of an endoscopy-oriented classification for pancreatic leaks.

Methods We retrospectively reviewed all patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for PLs between 1^st February 2012 and 31^st July 2024. Data collected included patient demographics, etiology of the PL, type of endoscopic treatment, need for second-line endoscopic interventions, technical and clinical success, early and late complications. PLs were classified as follows: type I for side branch leaks (subgroups IH: head, IB: body, IT: tail); type II for main pancreatic duct leaks, with subtypes II O (“open”) if no stricture or complete disruption is present, and II C (“closed”), otherwise. Type III leaks occur in surgically altered anatomy, with subtype IIID after pancreatoduodenectomy and subtype IIIP after distal pancreatectomy.

Results A total of 109 patients treated endoscopically for PLs or fistulas were included. Causes of pancreatic duct leaks included pancreatic or abdominal surgery (n=76), acute or chronic pancreatitis (n=22), trauma (n=8), and post-ERCP complications (n=3). The median age of patients was 61 years [IQR 46.0 – 72.0], with a male-to-female ratio of 82:27. At presentation, 31 patients (28.4%) had sepsis. In our population, PLs were distributed as follows: type I (n=16; subcategories IH n=5, IB n=2, IT n=9), type II (n=39; subcategories IIO n=28, IIC n=11), and type III (n=54; subcategories IIID n=34, IIIP n=20). This classification allowed targeted treatment selection. Technical success was achieved in 100% of cases, while clinical success was 84.4%, with 7.3% unevaluable due to loss to follow-up or death from other causes. Clinical success required a mean of 2 procedures for patient (IQR 1 – 3). Five out of 92 patients (5.4%) required an endoscopic ultrasound (EUS)-guided rendezvous procedure, and 4/109 (3.7%) underwent a combined ERCP-EUS treatment. Transitioning to an EUS-guided approach was necessary in 12/109 patients (11%) to achieve clinical success (Table 1).

Conclusions Our single-center experience shows high success rates achieved by tailoring treatment on the anatomic and functional features of the leak according to the above-mentioned classification. An endoscopy-oriented classification could lead to a better standardization of treatment, guide physician in the clinical setting and improve outcomes.

Publication History

Article published online:
27 March 2025