Transpapillary pancreatic duct stenting as a salvage therapy for refractory pancreatic fistula after distal pancreatectomy: a case series supporting the role of duodenal papilla obstruction.

BACKGROUND & AIMS: Endoscopic retrograde pancreatography (ERP) with pancreatic duct stenting is a recognized intervention for pancreatic fistulas. However, its application as a salvage therapy for refractory postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains less defined, particularly when guided by the hypothesis that duodenal papilla obstruction perpetuates the fistula. This study evaluated the efficacy of ERP with stenting for refractory POPF after DP and investigated the role of papilla morphology.

METHODS

Five patients with refractory Grade B POPF after DP were included. Refractoriness was defined as persistent high-output (> 100 mL/day) for > 3 weeks despite percutaneous drainage and medical therapy or newly developed pseudocysts. All patients underwent ERP. The key procedural goal was to traverse the papilla and place a stent into the pancreatic duct of the remnant to bypass any potential obstruction and achieve internal decompression.

RESULTS

ERP with trans-papillary stent placement was technically successful in all five patients (100%). Clinical success, defined as a dramatic reduction in fistula output (> 75%) within 72 h and complete fistula closure within 4 weeks, was achieved in all 5 patients (100%). No procedure-related complications occurred.

CONCLUSION

In this case series, ERP with pancreatic duct stenting is a highly effective and minimally invasive salvage therapy for refractory POPF after DP. Its consistent success provides strong clinical support for the pathophysiological role of duodenal papilla obstruction. We propose that ERP should be considered early in the management algorithm for high-output POPF that fails to resolve with standard measures.