Endoscopic Closure of Persistent Terminal Pancreatic Duct Leak Utilizing Fiber Ensealant. Primary Author, Thomas J. Tillman. Co-authors, James D. Haddad, Jorge Suarez, and Marcus Goldschmidt. These are our disclosures. A 33-year-old female without prior medical history presented following a motor vehicle collision resulting in pancreatic and splenic lacerations requiring distal pancreatectomy and splenectomy. Her postoperative course was complicated by refractory surgical bed fluid collections despite percutaneous drainage. ERCP was performed and demonstrated contrast extravasation from the distal aspect of the pancreatectomy site. Pancreatectomy with plastic pancreatic duct stenting was performed. Unfortunately, intraperitoneal fluid with an amylase concentration of greater than 27,000 units per liter continued to accumulate and leak control via endoscopic deployment of Fiber Ensealant was planned. A commercially available Fiber Ensealant product with its proprietary delivery mechanism was modified and connected to a modified double-lumen biliary dilation balloon catheter to allow for delivery via a side-viewing duodenoscope. A modified delivery system is necessary to avoid premature mixing of sealant components and to allow for successful deployment at the site of the leak. The equipment necessary for this procedure includes commercial Fiber Ensealant product, a double-lumen biliary dilation balloon catheter, and scissors or shears. The physician will begin by removing the original catheter from the deployment device, purging any excess air from the syringes, and connecting the adapter to the syringe deployment system, ensuring the pieces lock together tightly. Next, the double-lumen balloon catheter is removed from its packaging, and scissors or shears are used to transect the catheter proximal to the balloon, exposing the two lumens at the new distal end of the catheter. The proximal ports of the double-lumen balloon catheter are then connected to the adapter and locked tightly into place. The modified device is now ready for endoscopic deployment. In this case, the pancreatic duct stent was removed via ERCP, and a sphincteratome was advanced over a guide wire into the pancreatic duct. Contrast injection was used to localize the point of extravasation from the terminal pancreatic duct defect, and this area was marked on fluoroscopy. The modified double-lumen balloon catheter was then advanced over the guide wire to the point of the terminal pancreatic duct defect, and the guide wire was removed. The fiber and sealant components were delivered simultaneously at the site of the defect, and the catheter was retracted proximally. After five minutes, the area was interrogated with contrast without evidence of leakage. In this case, the patient required a high-risk surgical intervention, which was unfortunately complicated by a persistent pancreatic duct leak, for which repeat surgical intervention was considered to be of even greater risk. Our modified endoscopic approach allowed for a minimally invasive solution for the patient and avoidance of further surgical intervention. Leak control was rapidly achieved, and follow-up computed tomography one week following the procedure showed only a trace amount of fluid remaining in the surgical bed, which, when sampled, had an amylase concentration of 26 units per liter. Patients may encounter pancreatic duct leaks or fistulae as complications of trauma, surgery, or pancreatitis, and the optimal endoscopic approach to persistent pancreatic duct leaks is not established. Complex or persistent terminal pancreatic duct leaks can be successfully managed with endoscopic deployment of fiber and sealant. This technique is only recommended for terminal pancreatic duct defects, as deployment of sealant proximally could result in distal, main, and side duct obstruction.

endoscopic closure

persistent terminal pancreatic duct leak

Fiber Ensealant

pancreatic and splenic lacerations

motor vehicle collision