title: Endoscopic management of pancreatic fistula after enucleation of pancreatic tumors.
abstract: BACKGROUND
  Pancreatic fistula (PF) are frequent after pancreatic surgical resection, and particularly after enucleation. Endoscopic treatment might be proposed for postoperative PF, but has never been evaluated after pancreatic enucleation.
  
  
  METHODS
  From January 2000 to June 2012, 161 patients underwent pancreatic enucleation in our center. In case of PF in the postoperative period, conservative management (somatostatin analogs combined with enteral or parenteral nutrition and drainage) was proposed. If PF persisted after 20 days (output >50 cc/d), endoscopic treatment (pancreatic sphincterotomy and stent placement if evidence of main duct leakage) was proposed. Primary outcome was the delay of PF closure after endoscopic treatment.
  
  
  RESULTS
  Ninety-one patients (56 %) developed postoperative PF. PF closed within 3 weeks with conservative management in 78 (86 %) patients. Endoscopic treatment was required in 7 (8 %) patients. Daily PF output was 240 (50-300) mL. Pancreatic sphincterotomy was performed in all patients. A pancreatic stent was inserted in 4 of 5 patients with main pancreatic duct leakage. One patient presented a stent migration requiring a second procedure. No complication of endoscopic treatment was reported. The closure of PF was obtained in all cases, after 13 (3-24) days. Pancreatic stents were removed after 2, 5, 5, and 8 months, respectively. Median postoperative follow-up was 46 (21-70) months. At study endpoint, two patients had small asymptomatic pancreatic collections, four had mild dilatation of main pancreatic duct upstream pancreatic duct leakage, and none developed exocrine pancreatic insufficiency, diabetes, or recurrence of pancreatic tumor.
  
  
  CONCLUSIONS
  PF occurs in half patients after enucleation. Endoscopic treatment combining pancreatic sphincterotomy and stenting is safe and effective if conservative treatment fails, avoiding a complementary pancreatic resection.
authors.affiliation: Service de Gastroentérologie-Pancréatologie, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92118, Clichy Cedex, France. frederique.maire@bjn.aphp.fr.
authors.forename: Frédérique
authors.initials: F
authors.lastname: Maire
authors.affiliation: Service de Gastroentérologie-Pancréatologie, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92118, Clichy Cedex, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Ponsot
authors.affiliation: Service de Chirurgie Viscérale, Hôpital Beaujon, AP-HP, Clichy Cedex, France.|Paris-Diderot University, Paris, France.
authors.forename: Clotilde
authors.initials: C
authors.lastname: Debove
authors.affiliation: Service de Chirurgie Viscérale, Hôpital Beaujon, AP-HP, Clichy Cedex, France.|Paris-Diderot University, Paris, France.
authors.forename: Safi
authors.initials: S
authors.lastname: Dokmak
authors.affiliation: Service de Gastroentérologie-Pancréatologie, Hôpital Beaujon, AP-HP, 100 Boulevard du Général Leclerc, 92118, Clichy Cedex, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Ruszniewski
authors.affiliation: Service de Chirurgie Viscérale, Hôpital Beaujon, AP-HP, Clichy Cedex, France.|Paris-Diderot University, Paris, France.
authors.forename: Alain
authors.initials: A
authors.lastname: Sauvanet
mesh_terms: D000328:Adult; D000368:Aged; D004322:Drainage / Q000379:methods; D016145:Endoscopy, Digestive System / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000601:surgery*; D010183:Pancreatic Ducts / Q000601:surgery; D010185:Pancreatic Fistula / Q000209:etiology / Q000628:therapy*; D010190:Pancreatic Neoplasms / Q000601:surgery*; D011183:Postoperative Complications / Q000628:therapy*; D015607:Stents; D016896:Treatment Outcome
keywords: Enucleation; Pancreatic fistula; Pancreatic sphincterotomy; Pancreatic stent