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Background and Aims: Bilomas most frequently result from postoperative bile leaks. The endoscopic conventional treatment is sphincterotomy ± stent placement. In complex cases, such as altered anatomy or failure of conventional treatment, transpapillary/transfistulary (TP/TF) drainage or EUS-guided transmural drainage (EUS-TD) may obviate additional biliary surgery. This study reports our experience with treating biloma secondary to refractory biliary leak with TP/TF drainage or EUS-TD and evaluates the safety and outcomes associated with this approach., Methods: This observational study focused on consecutive patients managed for biliary leakage (diagnosis based on imaging and/or bile outflow from a surgical drain) at a tertiary care hospital (2007-2017). TP/TF drainage was performed by double-pigtail stent(s) placement to drain the biloma through the leak during ERCP. For EUS-TD, plastic stent(s) were placed under EUS control. Primary outcomes were a composite of clinical success (patient free of sepsis after percutaneous drain removal and, in patients with benign disease, removal of all endoscopically placed stents, without need for reintervention) and biloma regression (<3 cm) at last follow-up., Results: Thirty patients (men, 57%; median age, 55 years) were included. Most biliary leaks resulted from cholecystectomy (27%) and hepatectomy (50%). Initial EUS-TD and TP/TF drainage were performed in 14 (47%) and 16 (53%) patients, respectively. At last follow-up (median, 33.2 months), clinical success and primary outcome were achieved in 70.4% of patients (EUS-TD, 75%; TP/TF, 67%). Additional surgery was necessary in 1 patient. Rate of serious adverse events was 23% (7/30), of which 13% (4/30) were procedure related. There were 4 deaths during the course of treatment, 2 of which were related to endoscopic interventions (hemorrhage and fibrillation)., Conclusions: TP/TF drainage or EUS-TD is technically feasible with high clinical success and may avoid the need for additional surgery in complex cases or in patients with altered anatomy., (Copyright © 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Endoscopic transmural drainage is obtained by creating a communication between the intestinal tract and the pancreatic-fluid collection, and then inserting 1 or more stents. Collection recurrence after therapy is noted in 10% to 30% of cases. It is not known whether leaving the stents in position reduces recurrence rates., Objective: To test the hypothesis that patients who have undergone previous successful pancreatic-collection drainage and whose stents are retrieved have higher recurrence rates., Design: Randomized controlled trial., Setting: Tertiary referral center., Patients: During a period of 27 months, 46 of 77 patients who had undergone endoscopic transmural drainage for pancreatic collections met inclusion or exclusion criteria, and 28 of these patients were randomized., Interventions: Fifteen patients were assigned to group A, whose stents were left in place, and 13 were assigned to group B, whose stents were removed after collection resolution. The remaining 18 patients, who were not randomized, also had their stents left in place. All 46 patients were similarly followed., Main Outcome Measurement: Recurrence of the same pancreatic collection that required therapy., Results: All patients were followed for a median period of 14 months (interquartile range, 8.2-22 months) after treatment. The primary end point was reached in 5 patients in group B (stent retrieval), as opposed to none in group A (P = .013). Moreover, no recurrence was observed in the remaining 18 nonrandomized patients., Limitations: Small sample size., Conclusions: In patients who underwent successful transmural drainage of pancreatic collections, stent retrieval was associated with higher recurrence rates.

Objectives: Transpapillary drainage of the main pancreatic duct (MPD) has been proposed for the treatment of external pancreatic fistulas (EPF) but may not suffice to treat complex cases. The aim of the present study was to explore the efficacy of various endoscopic or combined percutaneous and endoscopic techniques in the treatment of EPFs., Methods: Sixteen patients presenting with EPFs were treated in our department. The techniques applied and patients' clinical outcome are described., Results: All but three patients underwent transpapillary MPD drainage by pancreatic sphincterotomy (N = 13). Additional endoscopic procedures performed were: (a) pancreatic fluid collection (PFC) drainage (N = 5), (b) transmural drainage between the fistula path and the gastrointestinal (GI) tract (N = 5), and (c) endoscopic ultrasound (EUS)-guided pancreaticoduodenostomy because of complete pancreatic duct rupture (N = 1). Fistula closure was achieved in all patients except one, who required surgery. During a median follow-up period of 18 months (range 6-52) three patients had fistula recurrence, and two, PFC recurrence. Both conditions were cured successfully by repeated endoscopic therapy. All recurrences occurred within 3 months of initial successful treatment., Conclusions: Combined endoscopic and percutaneous treatment appears to be safe and effective for the management of complex cases of EPFs.

Background: Pancreatic-fluid collections are frequent sequelae of acute and chronic pancreatitis, and endoscopic drainage of these collections has gained acceptance as an alternative to surgical drainage., Methods: Patient data, collection characteristics, drainage technique, and outcomes were obtained through chart review and prospective follow-up for 116 patients with attempted endoscopic drainage of symptomatic pancreatic-fluid collections., Results: A total of 116 patients presented with fluid collections classified as acute fluid collection (n = 5), necrosis (n = 8), acute pseudocyst (n = 30), chronic pseudocyst (n = 64), and pancreatic abscess (n = 9). The median diameter of the collection drained was 60 mm (15-275 mm). Median follow-up after drainage was 21 months. The drainage technique was transpapillary in 15 patients, transmural in 60, and both in 41. Successful resolution of symptoms and collection occurred in 87.9% of cases. No difference in success rates was observed between patients with acute pancreatitis and those with chronic pancreatitis. However, drainage of organized necrosis was associated with a significantly higher failure rate than other collections. No significant differences were observed regarding success when disease, drainage technique, or site of drainage was considered. Complications occurred in 13 patients (11%), and there were 6 deaths in the 30 days after drainage, including one that was procedure related., Conclusions: Endoscopic drainage of pancreatic-fluid collections is successful in the majority of patients and is accompanied by an acceptable complication rate.

The aim of this study was to quantify pancreatic exocrine function in normal subjects and in patients with chronic pancreatitis (CP) before and after pancreatic duct drainage procedures (PDDP) with dynamic secretin-enhanced magnetic resonance (MR) cholangiopancreatography (S-MRCP). Pancreatic exocrine secretions [quantified by pancreatic flow output (PFO) and total excreted volume (TEV)] were quantified twice in ten healthy volunteers and before and after treatment in 20 CP patients (18 classified as severe, one as moderate, and one as mild according to the Cambridge classification). PFO and TEV were derived from a linear regression between MR-calculated volumes and time. In all subjects, pancreatic exocrine fluid volume initially increased linearly with time during secretin stimulation. In controls, the mean PFO and TEV were 6.8 ml/min and 97 ml; intra-individual deviations were 0.8 ml/min and 16 ml. In 10/20 patients with impaired exocrine secretions before treatment, a significant increase of PFO and TEV was observed after treatment (P<0.05); 3/20 patients presented post-procedural acute pancreatitis and a reduced PFO. The S-MRCP quantification method used in the present study is reproducible and provides normal values for PFO and TEV in the range of those obtained from previous published intubation studies. The initial results in CP patients have demonstrated non-invasively a significant short-term improvement of PFO and TEV after PDDP.

Background & Aims: Endotherapy for patients with painful chronic pancreatitis (CP) gives early and midterm clinical results comparable with those of conventional surgery. The authors evaluated long-term clinical outcome after endoscopic pancreatic ductal drainage, focusing on pain and pancreatic endocrine/exocrine functions., Methods: Of 110 patients with painful CP endoscopically treated between October 1987 and December 1989, 56 long-surviving patients were followed-up for 14.4 years (SD, .6 y); 40 patients died and 14 patients were lost to follow-up evaluation. Technical results included decreased ductal dilation and stone clearance. Clinical results included the rate of hospitalizations for pain before and after endotherapy, the need for surgery, the course of endocrine/exocrine insufficiencies, and late mortality., Results: Complete or partial technical success initially was obtained in 48 of 56 long-surviving patients. Long-term clinical success (< or =5 hospitalizations for pain during follow-up evaluation, without surgery) was obtained for 37 of 56 patients. At a mean follow-up time of 14.4 years, 44 patients had avoided surgery and the annual rate of hospitalizations for pain decreased significantly (before endotherapy: 0.98 [+/-1.36] vs 0.40 [+/-0.51] for the 3 years thereafter vs 0.14 [+/-0.22] for the last 11 years of follow-up evaluation; P < .001). Short duration of disease before initial therapy and absence of smoking at the last follow-up evaluation were associated with long-term clinical success., Conclusions: Endotherapy provides long-term benefits for about two thirds of patients with painful CP. Good clinical outcome was associated with cessation or absence of smoking, whereas alcohol abuse increased the risks for diabetes mellitus, steatorrhea, and mortality.

Endoscopic management of CP is generally safe, minimally invasive, and often effective for years, does not hinder further surgery, and can be repeated. It should be applied as a first-line approach to improving the clinical condition of patients with this chronic disease. The best results are obtained when endoscopic treatment is performed early in the course of CP. Proper patient selection, adequate expertise, and a supporting multidisciplinary infrastructure are essential. New technologies will continue to be developed and to extend the scope of therapeutic pancreatic endoscopy.

Background: A prerequisite for endoscopic drainage of pancreatic fluid collections without EUS is the presence of a visible bulge in the GI wall. Our experience with endoscopic cystostomy of nonbulging pancreatic fluid collections is described., Methods: Thirty-three patients underwent 34 endoscopic attempts at transmural drainage of nonbulging pancreatic fluid collections over a 2-year period. The etiology of the nonbulging pancreatic fluid collections was chronic pancreatitis in 26 cases and acute pancreatitis in 7. Indications for drainage included one or more of the following: abdominal pain, infection, biliary obstruction, and external fistula. The diameter of the collections ranged from 20 to 160 mm (median 52 mm)., Results: Thirty-two of 34 drainage attempts were successful (94%). Eighteen cystostomies were performed under fluoroscopy alone and 14 by EUS together with fluoroscopy. Procedure-related complications occurred with 3 of 34 attempts (8%). Surgery was not required for treatment of the complications and there were no deaths from the procedure. Follow-up was available for 31 patients (median 21 months, range 9 to 40 months). One nonbulging pancreatic fluid collections recurred 7 months after drainage., Conclusions: Endoscopic cystenterostomy of nonbulging pancreatic collections is feasible, and the results of the procedure are similar to those of cystenterostomy for bulging collections.

Background: In severe chronic pancreatitis associated with intraductal stones, therapeutic endoscopy aims to reduce increased intraductal pressure by pancreatic sphincterotomy and stone clearance., Methods: Results of treatment were evaluated in 70 new patients who underwent pancreatic sphincterotomy and attempted stone removal. Technical results and frequency of pain relief and recurrence are compared., Results: Complete ductal clearance of calculi was obtained in 50% of cases. Immediate clinical improvement occurred in 95% of patients with painful attacks. No severe complications or mortality occurred. Fifty-four percent of all patients with painful chronic pancreatitis did not experience any pain recurrence within 2 years. Associations found to be statistically significant by multivariate analysis were ductal clearance and extracorporeal shock wave lithotripsy, pain disappearance and ductal clearance, pain recurrence and long evolution, and severe disease before treatment and presence of a ductal substenosis., Conclusions: In this subset of patients our results indicate that the pain of chronic pancreatitis is mainly related to increased intraductal pressure. Endoscopic management appears to be a safe, conservative, alternative to surgery. The best results are obtained when it is performed early in the course of calcifying chronic pancreatitis.