Radiology
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Fotoohi, M.
Right arrow Articles by vanSonnenberg, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Fotoohi, M.
Right arrow Articles by vanSonnenberg, E.
(Radiology. 1999;213:573-578.)
© RSNA, 1999

Vascular and Interventional Radiology

Persistent Pancreatocutaneous Fistula after Percutaneous Drainage of Pancreatic Fluid Collections: Role of Cause and Severity of Pancreatitis1

Mehran Fotoohi, MD, Horacio B. D'Agostino, MD 2, Bruce Wollman, MD, Kenneth Chon, MD, Seyed Shahrokni, BA and Eric vanSonnenberg, MD

1 From the Department of Radiology (C5-XR), Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98101 (M.F.); the Department of Radiology, University of California Medical Center, San Diego (H.B.D., B.W., S.S.); and the Department of Radiology, University of Texas Medical Branch at Galveston (K.C., E.v.S.). From the 1996 RSNA scientific assembly. Received August 14, 1998; revision requested October 15; revision received January 12, 1999; accepted April 30. Address reprint requests to M.F. (e-mail: radm1f@ix.netcom.com).


   Abstract
TOP
 Abstract
Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
PURPOSE: To assess the relationship between the cause and severity of pancreatitis and the development of persistent pancreatocutaneous fistula (PPCF) after percutaneous drainage of pancreatic fluid collections.

MATERIALS AND METHODS: Sixty patients (44 male, 16 female; age range, 10–74 years) were included in the study. The cause of pancreatitis was postoperative in 29 patients, alcoholism in 20 patients, biliary in six patients, hyperlipidemia in two patients, unknown in two patients, and trauma in one patient. Patients requiring intensive care unit treatment for their condition at the time of drainage were considered to have severe pancreatitis. Thirty-seven patients had mild pancreatitis, and 23 had severe pancreatitis. PPCF was defined as catheter drainage of pancreatic fluid of more than 10 mL/d for more than 4 weeks after catheter placement.

RESULTS: PPCF developed in 27 of the 60 patients. It occurred in five of the six patients with biliary pancreatitis, 10 of the 20 with alcohol-related pancreatitis, and 10 of the 29 with postoperative pancreatitis (P > .2). The prevalence of PPCF was higher in patients with severe pancreatitis (n = 16 [70%]) than in those with mild pancreatitis (n = 11 [30%]). This difference was statistically significant (P < .002).

CONCLUSION: Development of PPCF correlated with severity of pancreatitis, regardless of the cause of pancreatitis.

Index terms: Fistula, gastrointestinal tract, 77.289 • Pancreas, CT, 77.12111, 77.12112, 77.12115 • Pancreas, interventional procedures, 77.1263 • Pancreatitis, 77.291


   Introduction
TOP
 Abstract
 Introduction
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 
Treatment of acute pancreatitis includes general supportive measures, removal of the inciting cause if possible, and management of its complications. Fasting, total parenteral nutrition, and intravenous antibiotics are used to prevent stimulation of exocrine pancreatic secretion, provide nutrition, and prevent or treat sepsis, respectively (1,2). Pancreatic fluid collections may develop and complicate pancreatitis. As many as 42%–50% of pancreatic fluid collections resolve spontaneously (3,4). Symptomatic and infected pancreatic fluid collections require drainage. Surgical (5–9), endoscopic (10–12), and radiologic (13–17) techniques are used for external and internal drainage of pancreatic fluid collections. Surgical incision and external drainage have been used to resolve acute symptomatic and infected collections that lack an inflammatory wall. When the pancreatic fluid collection has a well-defined wall, internal drainage of the fluid collection into the gastrointestinal tract may be performed surgically or endoscopically (5,18,19). Imaging-guided percutaneous catheter insertion is a safe and effective alternative to surgery and endoscopy for drainage of pancreatic fluid collections in selected patients (13–17). Percutaneous drainage may be performed in symptomatic acute or chronic, sterile or infected pancreatic fluid collections. Although direct percutaneous external drainage is the most common approach used, percutaneous cystogastrostomy and cystoduodenostomy also are feasible for simulating internal surgical and endoscopic drainage (20–22).

A pancreatocutaneous fistula is created when a drainage catheter is inserted into a pancreatic fluid collection for external drainage. Pancreatocutaneous fistulas result from surgical and percutaneously placed drainage catheters. Skin erosions and hemorrhage may complicate surgical pancreatocutaneous fistulas in 17%–36% of cases (23–25). To our knowledge, these adverse effects as complications of pancreatocutaneous fistulas after percutaneous drainage have not been described. A persistent pancreatocutaneous fistula (PPCF) is characterized by prolonged duration of catheterization, and vigorous patient treatment and catheter management are required to achieve its closure. We performed the present study to assess the relationship between the cause and severity of pancreatitis and the development of PPCF.


   MATERIALS AND METHODS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 References
 
From July 1988 to March 1997, 60 consecutive patients (44 male, 16 female; age range, 10–74 years; mean age, 41.7 years) with symptomatic pancreatic fluid collections complicating pancreatitis underwent percutaneous drainage. The cause of pancreatitis in 29 (48%) patients was postoperative; in 20 (33%), alcoholism; in six (10%), biliary; in two (3%), hyperlipidemia; in two (3%), unknown; and in one (2%), trauma. Complete laboratory data for analysis with Acute Physiology and Chronic Health Evaluation II scores or Ranson criteria were not available in the majority of patients; therefore, their clinical status was used to categorize the severity of pancreatitis. Patients who were able to sustain their vital functions in the hospital ward were considered to have mild pancreatitis. Patients who required intensive care unit treatment for their condition at the time of drainage were considered to have severe pancreatitis. Thirty-seven (62%) patients had mild pancreatitis, and 23 (38%) had severe pancreatitis. The percentages of patients with mild and severe pancreatitis as categorized by cause are summarized in Table 1.


View this table:
[in this window]
[in a new window]
  		TABLE 1. Cause and Severity of Pancreatitis
 
Pancreatic fluid collections were diagnosed by using computed tomography (CT) of the abdomen. The diagnostic studies were performed by using approximately 900 mL of gastrointestinal contrast material (1.5% barium sulfate [READI-CAT 2]; E-Z-EM, Westbury, NY) after acquiring an initial scan without administration of intravenous contrast material through the upper region of the abdomen for detection of hemorrhage. The studies were completed by obtaining contrast material–enhanced CT scans of the abdomen and pelvis with 150 mL of 60% iothalamate meglumine (Conray 60; Mallinckrodt Medical, St Louis, Mo) administered at a rate of 3 mL/sec. The scanning delay after the contrast material injection was approximately 60–70 seconds for abdominal CT. The scanning delay for the pelvic component of the examination was approximately 120 seconds after the contrast material injection. In 38 patients, the scans were obtained by using a model 9800 series scanner (HiLite Advantage; GE Medical Systems, Milwaukee, Wis) with contiguous, 10-mm-collimation sections. In 22 patients, a helical CT scanner (CT HiSpeed Advantage; GE Medical Systems) was used with contiguous, 7-mm-collimation sections. All CT scanning was performed from the diaphragm through the ischial tuberosities. In patients with persistent symptoms, follow-up CT scans were obtained with intravenous contrast material after drainage on a weekly basis. Once the symptoms, sepsis, and/or drainage ceased, repeat CT was considered to be unnecessary.

The indication for percutaneous drainage was sepsis in 38 (63%), pain in 20 (33%), and biliary obstruction in two (3%) patients. The imaging guidance used for percutaneous drainage was ultrasonography (US) combined with fluoroscopy in 35 (58%), CT in 22 (37%), and CT combined with fluoroscopy in three (5%) patients. The primary clinical service started all patients on a broad variety of antibiotics before drainage. The approach for percutaneous drainage was direct in 53 (88%), transgastric in four (7%), and transhepatic in three (5%) patients. For drainage, single-lumen, locking pigtail catheters were used in 50 patients; double-lumen, locking pigtail catheters were used in 10 patients; and Malecot catheters were used in three patients.

The catheters were selected on the basis of the characteristics of the fluid obtained in the diagnostic aspiration that preceded the drainage. Thirty-nine patients had viscous fluid and fluid that contained particles, which was drained by using large (12–24-F) catheters. Twenty-one patients had low-viscosity fluid, which was drained by using 8–10-F catheters. In 35 patients, the catheters were inserted by using the Seldinger technique, and in 25 patients they were inserted by using the trocar technique. In the 33 patients who had multiple collections and/or collections with either viscous fluid or fluid that contained particles, the fluid was drained by using multiple catheters. In 27 patients, a single catheter was used for drainage.

Evacuation of the collection cavity was assessed by performing US or CT immediately after drainage. If fluid was left in the cavity, the catheter was repositioned or an additional catheter was inserted. The collection cavity was irrigated with aliquots of normal saline solution until the aspirated irrigation solution became clear. The aliquots of normal saline solution were 1/4–1/5 the total volume of the fluid collection. The catheters used to drain low-viscosity fluid were connected to a bag to drain by means of gravity. Low intermittent suction was used when the fluid drained was viscous or contained particles. Ten-milliliter aliquots of normal saline solution were used for catheter irrigation every 8 hours or more frequently (ie, every 4–6 hours) for catheters used to drain viscous fluid or fluid with particles.

Elective catheter exchange was performed every 7–10 days in 36 patients who had collections that contained necrotic debris. Patient treatment included nutritional support and antibiotic therapy. While the patients were in the hospital, they received total parenteral nutrition. Jejunal feedings by means of percutaneous gastrojejunostomy were required in one patient, who had severe pancreatitis and repeated central venous line infections. Patients who were discharged or were ambulatory were started on a low-fat diet. PPCF was defined as catheter drainage of pancreatic fluid of more than 10 mL/d for more than 4 weeks after insertion of the drainage catheter.

Catheter sinography was performed in 37 patients with prolonged drainage to assess the communication between the fluid collections and the pancreatic duct or gastrointestinal tract and to evaluate the cavity size. Octreotide was administered to 32 (53%) patients once active pancreatitis and sepsis had resolved. Indications for the use of octreotide included having undergone drainage as an outpatient or the development of PPCF. The dose of octreotide ranged from 50 to 1,000 µg, which was administered subcutaneously every 8 hours. The catheters were removed when the symptoms and sepsis resolved, no fistula was demonstrable at catheter sinography, and the daily drainage output was less than 10 mL/d for 2 days. Percutaneous catheter drainage was considered to be successful when the symptoms disappeared and the pancreatic fluid collection resolved during the follow-up period. The criterion for drainage failure was the requirement of surgical intervention for resolution of the pancreatic fluid collection after catheter drainage.

From July 1988 to August 1992, patient follow-up data were obtained from 10 patients' charts, and from September 1992 to March 1997 50 patients were followed up at the interventional radiology clinic. Additional imaging examinations, catheter exchange, and catheter sinography were performed as needed during the follow-up period. The ambulatory patients who were tolerating a low-fat diet and whose symptoms were resolving were discharged with the catheters in place and given instructions on catheter care at home. These patients were followed up weekly at the interventional radiology clinic. Patients were seen 1 week, 1 month, and 3 months after discharge from the hospital and encouraged to return after 6 months and then yearly thereafter. The data on 23 (38%) patients who did not comply with this regimen were updated through chart review. The follow-up period after catheter removal ranged from 10 days to 84 months (median, 8 months).

The two-tailed Student t test was used to evaluate the statistical significance of the cause and severity of pancreatitis in the development of PPCF. The average duration of catheterization in each patient was calculated, with consideration of the cause and severity of pancreatitis. A P value of less than .05 was considered to be significant.


   RESULTS
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 References
 
Successful drainage was achieved in 54 (90%) of the 60 patients. Four of these 54 patients (7%) had recurrence of their collection 5 days to 12 months after catheter drainage. These patients were treated successfully with additional percutaneous drainage. Drainage failure occurred in three (5%) patients, who required surgical treatment. The 30-day mortality rate in all 60 patients was 5% (three patients); that in the 23 patients with severe pancreatitis was 13% (three patients). All three patients died of multiorgan failure within 1 week after catheter insertion. The drainage failure and mortality rates in this series are summarized in Table 2. The following complications occurred in six (10%) patients: fistulization in the gastrointestinal tract in two patients, catheter dislodgment in two patients, sepsis in two patients, and hemorrhage in one patient.


View this table:
[in this window]
[in a new window]
  		TABLE 2. Drainage Failure and Mortality
 
A total of 120 catheters were placed in 60 patients without adverse effects. Patients required single or multiple catheters for adequate drainage of fluid collections; one to 11 catheters were used per patient (average, two catheters per patient). The catheters ranged in size from 8- to 24-F (median size, 12 F). The most frequently used catheter size was 12-F (in 32 patients). The volume of fluid evacuated at the time of catheter insertion ranged from 20 to 2,000 mL (average volume, 469 mL). Bacteriologic studies of the fluid yielded microorganisms in 44 (73%) patients. Enteric bacteria were the most common pathogens cultured.

The durations of catheterization in this series ranged from 4 to 279 days (average, 50.6 days). The average durations of catheterization for pancreatic fluid collection in patients with biliary pancreatitis, postoperative pancreatitis, and alcohol-related pancreatitis were 70.2, 57.4, and 38.4 days, respectively (P > .2). PPCF developed in 27 (45%) of the 60 patients, including five (83%) of six patients with biliary pancreatitis, 10 (50%) of 20 patients with alcohol-related pancreatitis, and 10 (34%) of 29 patients with postoperative pancreatitis (Fig 1). The average duration of catheterization in the patients with severe pancreatitis was 79.2 days; that in the patients with mild pancreatitis was 31.9 days. PPCF developed in 16 (70%) of the 23 patients with severe pancreatitis and in 11 (30%) of the 37 patients with mild pancreatitis (P < .002).



View larger version (138K):
[in this window]
[in a new window]
  		Figure 1a. Severe pancreatitis after cardiac surgery in a 10-year-old boy who developed a PPCF (duration of catheterization, 47 days). In a and b, P = pancreas. (a) Transverse abdominal CT scan shows large heterogeneous retrogastric pancreatic fluid collection (arrowheads) displacing the stomach (arrow) anteriorly and medially. (b) Transverse abdominal CT scan obtained 3 months after removal of the drainage catheters shows resolution of the fluid collection. S = spleen.

 


View larger version (129K):
[in this window]
[in a new window]
  		Figure 1b. Severe pancreatitis after cardiac surgery in a 10-year-old boy who developed a PPCF (duration of catheterization, 47 days). In a and b, P = pancreas. (a) Transverse abdominal CT scan shows large heterogeneous retrogastric pancreatic fluid collection (arrowheads) displacing the stomach (arrow) anteriorly and medially. (b) Transverse abdominal CT scan obtained 3 months after removal of the drainage catheters shows resolution of the fluid collection. S = spleen.

 
In 28 (76%) of 37 patients, catheter sinography demonstrated no communication between the fluid collection and the pancreatic duct or gastrointestinal tract. In nine (24%) of 37 patients, a communication between the fluid collection and either the pancreatic duct (in seven patients) or the gastrointestinal tract (in two patients) was demonstrated. The average duration of catheterization in the patients with fluid collections that communicated with either the pancreatic duct or the gastrointestinal tract (57.9 days) was similar to that in the patients without such a communication (58.8 days). The PPCF resolved in 26 (96%) of 27 patients, including two patients with distal pancreatic ductal obstruction (Fig 2) and one with distal pancreatic ductal stenosis. One (4%) ambulatory patient who developed PPCF was lost to follow-up.



View larger version (147K):
[in this window]
[in a new window]
  		Figure 2a. Closure of PPCF after complete distal pancreatic ductal obstruction in a 64-year-old woman who had severe pancreatitis after endoscopic placement of a biliary stent (curved arrow in a), with a pancreatic head mass. In a and b, P = pancreas. (a) Transverse abdominal CT scan shows a large pancreatic fluid collection (arrowheads) involving the perinephric space and the anterior and posterior pararenal spaces. There is mild dilatation of the pancreatic duct (straight arrow). The patient developed duodenal obstruction and obstructive jaundice. (b) Transverse abdominal CT scan obtained after removal of the drainage catheter shows resolution of the pancreatic fluid collection (duration of catheterization, 8 months). There is atrophy of the gland, with marked dilatation of the chronically obstructed pancreatic duct (white arrow). Note the percutaneous cholecystotomy catheter (arrowhead) used for biliary decompression and the gastrojejunostomy catheter (black arrow) used for enteral nutrition and infusion of the bile drained with the cholecystotomy catheter.

 


View larger version (136K):
[in this window]
[in a new window]
  		Figure 2b. Closure of PPCF after complete distal pancreatic ductal obstruction in a 64-year-old woman who had severe pancreatitis after endoscopic placement of a biliary stent (curved arrow in a), with a pancreatic head mass. In a and b, P = pancreas. (a) Transverse abdominal CT scan shows a large pancreatic fluid collection (arrowheads) involving the perinephric space and the anterior and posterior pararenal spaces. There is mild dilatation of the pancreatic duct (straight arrow). The patient developed duodenal obstruction and obstructive jaundice. (b) Transverse abdominal CT scan obtained after removal of the drainage catheter shows resolution of the pancreatic fluid collection (duration of catheterization, 8 months). There is atrophy of the gland, with marked dilatation of the chronically obstructed pancreatic duct (white arrow). Note the percutaneous cholecystotomy catheter (arrowhead) used for biliary decompression and the gastrojejunostomy catheter (black arrow) used for enteral nutrition and infusion of the bile drained with the cholecystotomy catheter.

 

   DISCUSSION
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
References
 
In our series, PPCF occurred more frequently in patients who had severe pancreatitis, regardless of the cause of pancreatitis. The severity of pancreatitis correlated with prolonged duration of catheterization and increased prevalence of PPCF. The difference in the development of PPCF between patients with severe pancreatitis and those with mild pancreatitis was statistically significant (P < .002). Our data indicate that the cause of pancreatitis may not be relevant in the development of PPCF. The relationship between the different causes of pancreatitis and the development of PPCF was not statistically significant (P > .2). Although most patients with biliary pancreatitis also had severe pancreatitis, the number of patients with biliary pancreatitis was small in our series. Further data from an analysis of the possible relationship between biliary pancreatitis and severe pancreatitis would be useful.

The goal of percutaneous catheter drainage is the resolution of the pancreatic fluid collection. The success of the procedure and closure of the PPCF are achievable with active participation by and continuous interaction between the gastroenterologist, surgeon, and interventionalist (13,26–29). Follow-up of patients after percutaneous drainage of pancreatic collections is demanding (15,26–29). Daily clinical rounds are essential for evaluating the performance of the drainage catheters and the condition of critically ill patients. In addition to daily catheter irrigation, catheters are replaced periodically to help clear the collection cavity of infected debris (15,29). Changes in nutritional support and antibiotics, as well as performance of repeat imaging in the patient, may result from discussions with the nonradiologist colleagues involved.

Most patients with PPCF leave the hospital with a drainage catheter in place (29). Therefore, it is advantageous for the interventionalist to have an outpatient clinic where he or she can provide continued care for these ambulatory patients (30). The interventional clinic provides the professional environment for the organized follow-up that is necessary for decisions regarding timely imaging studies such as catheter sinography and abdominal CT, compliance with dietary recommendations, catheter removal, and accurate evaluation of percutaneous drainage results (30).

Additional measures that promote resolution of PPCFs include catheter manipulation and octreotide administration. Once the fluid collection and sepsis have resolved and a solid, walled-off tract is seen from the tip of the catheter to the skin at catheter sinography, reducing the size of the drainage catheter will reduce the size of the tract (15). In addition, in patients with PPCF, a straight, red Robinson catheter may be used to replace the locking pigtail catheter when the tract size is about 8 F. This straight, rubber catheter will enable sequential catheter withdrawal in 2–4 days when the parameters for catheter removal are met. Progressive catheter removal is presumed to facilitate the closure of the tract from the inside out.

Octreotide is a synthetic compound that inhibits secretions from several endocrine and exocrine glands, including exocrine pancreatic secretions (31). Subcutaneously or intravenously administered octreotide has been used successfully to decrease the drainage volume from surgical pancreatic fistulas and the PPCFs from percutaneous drainage of pancreatic fluid collections (32,33). Its therapeutic effect is apparent within 24–48 hours after its administration. Octreotide should be added to the PPCF treatment regimen after the active pancreatitis and sepsis have resolved (15). The drug is well tolerated; its most common adverse effect is local burning at the site of the subcutaneous injection (31).

Distal pancreatic ductal disruption or obstruction may be considered to be a relative contraindication to percutaneous drainage (34,35). These patients can develop PPCFs following percutaneous drainage. However, resolution of pancreatic fistulas with atrophy of the proximal portion of the gland has been reported in some of these patients (36). In our series, this event was seen in one patient with obstruction of the distal pancreatic duct.

Endoscopic transpapillary placement of pancreatic stents may be an alternative approach to treating PPCFs (36). Stents placed in the pancreatic duct are expected to promote healing of the fistula by directly occluding the pancreatic ductal leak or by improving pancreatic drainage into the duodenum (36,37). Kozarek et al (36) used this method successfully in eight of nine patients with refractory pancreatocutaneous fistulas. The complications associated with endoscopic transpapillary placement of pancreatic stents include stricture or occlusion of the pancreatic duct, internal or external migration of the stent, and iatrogenic lesions (ie, duodenal perforation, pancreatitis) (36,38,39).

In conclusion, patients with severe pancreatitis may be expected to develop PPCF after percutaneous drainage. The cause of pancreatitis alone does not influence the duration of catheterization. Patient treatment and catheter management are essential to resolving PPCFs.


   Footnotes
 
2 Current address: Department of Radiology, Louisiana State University Health Sciences Center, Shreveport, La. Back

Abbreviation: PPCF = persistent pancreatocutaneous fistula

Author contributions: Guarantors of integrity of entire study, H.B.D., M.F.; study concepts and design, H.B.D., M.F.; definition of intellectual content, H.B.D.; literature research, H.B.D., M.F.; clinical studies, H.B.D., M.F., E.v.S., K.C.; data acquisition, all authors; data analysis, H.B.D., M.F., E.v.S.; statistical analysis, H.B.D., M.F.; manuscript preparation, H.B.D., M.F.; manuscript editing and review, H.B.D., M.F., E.v.S.


   References
TOP
 Abstract
 Introduction
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 References
 

  1. Steinberg W, Tenner S. Acute pancreatitis. N Engl J Med 1994; 330:1198-1210.[Free Full Text]
  2. Steinberg W. Diagnosis and management of acute pancreatitis. Cleve Clin J Med 1997; 64:182-186.[Medline]
  3. Bradley EL, III, Clements JL, Gonzales AC. The natural history of pancreatic pseudocysts: a unified concept of management. Am J Surg 1979; 137:135-141.[Medline]
  4. Imrie CW, Shearer CW. Spontaneous resolution of pancreatic pseudocysts (abstr). Digestion 1990; 46:177-178.
  5. O'Malley VP, Cannon JP, Postier RG. Pancreatic pseudocysts: cause, therapy, and results. Am J Surg 1985; 150:680-682.[Medline]
  6. Mughal MM, Bancewicz J, Irving MH. The surgical management of pancreatic abscess. Ann R Coll Surg Engl 1987; 69:64-70.[Medline]
  7. Kohler H, Schafmayer A, Ludtke FE, et al. Surgical treatment of pancreatic pseudocysts. Br J Surg 1987; 74:813-815.[Medline]
  8. Katsohis CD, Jardinoglou E, Basdanis G, Aletras HA. Pancreatic abscess following acute pancreatitis. Am Surg 1989; 55:427-434.[Medline]
  9. Andersson R, Janzon M, Sundberg I, Bengmark S. Management of pancreatic pseudocysts. Br J Surg 1989; 76:550-552.[Medline]
  10. Huibregtse K, Schneider B, Vrij AA, Tytgat GN. Endoscopic pancreatic drainage in chronic pancreatitis. Gastrointest Endosc 1988; 34:9-15.[Medline]
  11. Kozarek RA, Patterson DJ, Ball TJ, Traverso LW. Endoscopic placement of pancreatic stents and drains in the management of pancreatitis. Ann Surg 1989; 209:261-266.[Medline]
  12. Dohmoto M, Rupp KD. Endoscopic drainage of pancreatic pseudocysts. Surg Endosc 1992; 6:118-124.[Medline]
  13. vanSonnenberg E, Wittich GR, Casola G, et al. Percutaneous drainage of infected and noninfected pancreatic pseudocysts: experience in 101 cases. Radiology 1989; 170:757-761.[Abstract/Free Full Text]
  14. Freeny PC, Lewis GP, Traverso LW, Ryan JA. Infected pancreatic fluid collections: percutaneous catheter drainage. Radiology 1988; 167:435-441.[Abstract/Free Full Text]
  15. D'Agostino HB, Fotoohi M, Aspron MM, et al. Percutaneous drainage of pancreatic fluid collections. Semin Interv Radiol 1996; 13:101-136.
  16. Stanley JH, Gobien RP, Schabel SI, et al. Percutaneous drainage of pancreatic and peripancreatic fluid collections. Cardiovasc Intervent Radiol 1988; 11:21-25.[Medline]
  17. Adams DB, Harvey TS, Anderson MC. Percutaneous catheter drainage of pancreatic pseudocysts. Am Surg 1991; 57:29-33.[Medline]
  18. Warshaw AL, Rattner DW. Timing of surgical drainage for pancreatic pseudocyst: clinical and chemical criteria. Ann Surg 1985; 202:720-724.[Medline]
  19. Shatney CH, Lillehei RC. The timing of surgical treatment of pancreatic pseudocysts. Surg Gynecol Obstet 1981; 152:809-812.[Medline]
  20. Davies RP, Cox MR, Wilson TG, et al. Percutaneous cystogastrostomy with a new catheter for drainage of pancreatic pseudocysts and fluid collections. Cardiovasc Intervent Radiol 1996; 19:128-131.[Medline]
  21. Bilbao JI, Alejandre PL, Longo JM, et al. Percutaneous transgastric cystoduodenostomy in the treatment of a pancreatic pseudocyst: a new approach. Cardiovasc Intervent Radiol 1995; 18:422-4225.[Medline]
  22. Das K, Kochhar R, Kaushik SP, et al. Double pigtail cystogastric stent in the management of pancreatic pseudocyst. JCU 1992; 20:11-17.
  23. Jordan JL. Pancreatic fistula. Am J Surg 1970; 119:200-207.[Medline]
  24. Martin FM, Rossi RL, Munson JL, et al. Management of pancreatic fistulas. Arch Surg 1989; 124:571-573.[Abstract]
  25. Tsiotos GG, Smith D, Sarr MG. Incidence and management of pancreatic and enteric fistulas after surgical management of severe necrotizing pancreatitis. Arch Surg 1995; 130:48-52.[Abstract]
  26. Freeny PC, Hauptmann E, Althouse SJ, Traverso LW, Sinanan M. Percutaneous CT-guided catheter drainage of infected acute necrotizing pancreatitis: techniques and results. AJR 1998; 170:969-975.[Abstract/Free Full Text]
  27. Mueller PR. Percutaneous drainage of pancreatic necrosis: is it ecstasy or agony? (commentary). AJR 1998; 170:976-977.[Abstract/Free Full Text]
  28. Vogelzang R. Clinical care: perception or reality? (editorial). Society of Cardiovascular and Interventional Radiology News 1997; 10:3.
  29. Echenique AM, Sleeman D, Yrizarry J, et al. Percutaneous catheter-directed debridement of infected pancreatic necrosis: results in 20 patients. JVIR 1998; 9:565-571.[Medline]
  30. Wollman B, D'Agostino HB, Johnson D, Beale A, Clark J, Pittman C. Improvement in patient care and operational efficiency: experience with a non-vascular interventional radiology clinic. J Intervent Radiol 1998; 12:1-4.
  31. D'Agostino HB, vanSonnenberg E, Sanchez RB, et al. Treatment of pancreatic pseudocysts with percutaneous drainage and octreotide. Radiology 1993; 187:685-688.[Abstract/Free Full Text]
  32. Pederzoli P, Bassi C, Falconi M, et al. Conservative treatment of external pancreatic fistulas with parenteral nutrition alone or in combination with continuous intravenous infusion of somatostatin, glucagon or calcitonin. Surg Gynecol Obstet 1986; 163:428-432.[Medline]
  33. Prinz RA, Pickleman J, Hoffman JP. Treatment of pancreatic cutaneous fistulas with a somatostatin analog. Am J Surg 1988; 155:36-42.[Medline]
  34. Freeny PC. Acute pancreatic fluid collections and pseudocysts: CT diagnosis and percutaneous catheter drainage. In: Bradley EL, III, eds. Acute pancreatitis: diagnosis and therapy. New York, NY: Raven, 1994; 197-206.
  35. Ahearne PM, Baillie JM, Cotton PB, et al. An endoscopic retrograde cholangiopancreatography (ERCP)-based algorithm for the management of pancreatic pseudocysts. Am J Surg 1992; 163:111-116.[Medline]
  36. Kozarek RA, Ball TB, Patterson DF, et al. Transpapillary stenting for pancreaticocutaneous fistulas. J Gastrointest Surg 1997; 1:357-361.[Medline]
  37. Kozarek RA, Traverso LW. Pancreatic fistulas: etiology, consequences, and treatment. Gastroenterologist 1996; 4:238-244.[Medline]
  38. Kozarek RA. Pancreatic stents can induce ductal changes consistent with chronic pancreatitis. Gastrointest Endosc 1990; 36:93-95.[Medline]
  39. Sherman S, Alvarez C, Robert M, et al. Polyethylene pancreatic duct stent-induced changes in the normal dog pancreas. Gastrointest Endosc 1993; 39:658-664.[Medline]




This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Fotoohi, M.
Right arrow Articles by vanSonnenberg, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Fotoohi, M.
Right arrow Articles by vanSonnenberg, E.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
RADIOLOGY RADIOGRAPHICS RSNA JOURNALS ONLINE