Image Guided Percutaneous Pancreatic Duct Drainage: What for and How?

Abstract

Background

     Various non-malignant and malignant pathologies of pancreas, duodenum, major papilla and retroperitoneal space, associated with pancreatic duct obstruction may lead to initiation of pancreatitis and also to either initiation, or rapid advancement of existing diabetes.  

Aim

     To present the rationale and technique  of image guided percutaneous pancreatic duct drainage (PPDD) for treating pancreatic duct (PD) obstruction.

Material & Methods

  In total, 73 patients underwent PPDD. All procedures were performed under moderate sedation and local anesthesia.

  Three types of imaging guidance were used, including combined US and fluoroscopy guidance (n = 40), combined CT and fluoroscopy guidance (n = 26), and CT guidance only (n = 7). The patients were categorized into 2 groups based on the type of diagnosis: patients without malignancy (n = 26) with PD obstruction due to acute and chronic pancreatitis (n = 25) or postoperative stricture (n = 1) and patients with malignancy (n = 47) with pancreatic

head tumors (n = 42) and ampullary tumors (n = 5).

Results

Image-guided PPDD was attempted with an overall technical success rate of 98.6% (72/73). In 66 of 73 (90.4%) patients, PD drainage was accomplished in a single procedure; 5 (6.8%) and 2 (2.7%) patients required 2 and 3

attempts, respectively. A total of 94 procedures were performed on 73 patients, with a mean of 1.2 procedures per patient.

In 13 of 73 (17.8%) patients in whom the PD tail segment was accessed through the posterior approach, only the abdominal wall and retroperitoneal fat were traversed. Retroperitoneal hydro - or air dissection for  

secure passage tract creation was performed to 5 (6.8%) patients and 1 (1.4%) patient, respectively. The anterior approach was employed in 60 (82.2%) patients. In 5 patients, a 14-gauge needle steering was used to

avoid traversing the stomach and colon. In 35 (50%) patients, only the abdominal wall was traversed. Transhepatic and transgastric routes were used in 13 (17.8%) and 12 (16.4%) patients, respectively.

In all cases, external catheters were maintained until recanalization or surgery was performed. The mean drainage fluid output after PD was 630 mL/d ± 279, which progressively increased over 1 week.

All patients improved gradually. Thirteen (17.8%) patients presented with new-onset DM, of whom 8 had pancreatic cancer, 2 had recurrent chronic pancreatitis, and 3 had PD stones. A significant decrease in blood glucose levels was observed in these patients between 2 and 5 weeks after PD drainage. Three (4.1%) patients had a long history of chronic DM, and they did not show an improved glycemic control after PPDD.

      Four (5.5%) asymptomatic patients underwent PPDD before pancreaticoduodenectomy at the surgeon’s request and had drainage catheters left in place for 2–3 weeks after surgery to maintain access to the pancreaticojejunal anastomosis in case adjunctive procedures were needed.

Conclusion

image-guided PPDD is a feasible and valuable therapeutic procedure in a large cohort of patients with various malignant and nonmalignant pathologies.