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Background and aim: A 40-year-old male was referred to our institute for the management of a percutaneous pancreatic fistula after acute pancreatitis due to SARS-COV2 infection. He developed a peripancreatic collection(PPC) which was percutaneously drained due to infection. After the resolution of PPC, a percutaneous leakage of the main pancreatic duct (MPD) was observed, so he underwent Endoscopic Retrograde ColangioPancreatography(ERCP) with biliary plus pancreatic sphincterotomy and placement of both pancreatic and biliary stent without resolution of the leak. Material(s) and Method(s): Then he was referred to our institution, where initial management included ERCP with placement of two trans-papillary pancreatic stents and the removal of percutaneous catheter, but the fistula kept to drain. Result(s): A multidisciplinary-board decided to perform a rendezvous with interventional radiology to facilitate an endoscopic ultrasound(EUS) trans-gastric drainage of the pancreatic area draining in the percutaneous fistula. Conclusion(s): The procedure included an initial ERCP with replacement of the two pancreatic stents while the radiologist places percutaneously a guidewire through the fistula to the pancreatic point of leakage into MPD. After that, EUS identified the point in which the percutaneous guidewire was getting into the MPD and a trans-gastric EUS-guided insertion of a guidewire achieved the MPD through a 19-Gauge needle. The latter guidewire crossed the percutaneous fistula and came out. At that point, a dilation up to 10 mm was performed to create a trans-gastric pancreatic fistula. The next step was to insert percutaneously a double pigtail(10 Fr) releasing the distal side into the stomach and the proximal side into the main pancreatic duct in order to stabilize the neo-fistula. Another trans-gastric plastic stent was endoscopically placed through the pancreato-gastric neo-fistula. At the end, injection of contrast dye through the percutaneous fistula showed a complete drainage into stomach. In conclusion, the procedure achieved the complete exclusion and resolution of the pancreatic-cutaneous fistula.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.
RESUMO
Background: Coronavirus disease 2019 (COVID-19) has affected more than 249 million people worldwide as of November 2021. Patients with chronic immune-mediated inflammatory diseases are at risk of viral infections either related to their underlying immune dysfunction or the immunosuppressive therapy, but little is known about the impact of COVID19 on outcomes and management of pancreatobiliary IgG4 related disease (IgG4 RD) patients. Methods: This was a multicenter retrospective cohort study aiming to investigate the impact of COVID-19 on the clinical outcomes and management of pancreatobiliary IgG4 RD patients in different geographic areas with COVID-19 outbreak. Pancreatobiliary IgG4 RD patients aged 18 years or older from 7 referral centers in Hong Kong, Japan, Thailand, Singapore, the United States and Italy were included. Case definition of IgG4 RD: elevated serum IgG4 serology with typical features of pancreatobiliary involvement on imaging, EUS, ERCP and/ or typical histopathologic features of IgG4 RD. Medical records were reviewed for IgG4 RD status (organ involvement, disease activity, treatment status), COVID-19 infection and outcome. Outcome measures were incidence and severity of COVID-19 in pancreatobiliary IgG4 RD patients, medical treatment for the IgG4 disease during COVID-19 and incidence of postponement or discontinuation of indicated medical treatment for IgG4 RD during COVID-19. Results: 101 pancreatobiliary IgG4 RD patients (mean age 66.4 +/- 12.1 years, male 74.3%) from 7 referral centers were included from January 2020 to November 2020. Major comorbidities of patients: none in 21.8%, diabetes in 45.5%, hypertension in 49.5%, ischemic heart disease in 8.9%, chronic liver disease in 8.9%, chronic kidney disease in 9.9% and cancer in 5.0% of patients. IgG4 RD organ involvement: pancreas only in 36.6%, pancreas and bile duct in 16.8%, bile duct only in 14.9%, pancreatobiliary and other organs in 26.7% of patients. The mean serum IgG4 serology level was 4.72+/-7.31 g/L. In 2020, 27.7% of patients had active IgG4 disease while 72.3% of patients were in remission. In 2020, 65.3% of patients received treatment (steroid in 48.5%, thiopurines in 22.7%, steroid and thiopurines in 25.8%, rituximab in 1.5%), while 30.7% of patients were not on treatment. 2 patients (2.0%) had COVID-19 infection, with 1 patient requiring ICU admission. All infected patients recovered from COVID-19 without flare up of IgG4 RD. In 2020, 6.9% of patients had postponement or discontinuation of indicated medical treatment for IgG4 RD during COVID-19 outbreak due to concern of COVID-19 infection while on immunosuppressive therapy. Conclusion: In this study, low incidence of COVID-19 infection and low rates of postponement or discontinuation of indicated medical treatment were observed in pancreatobiliary IgG4 RD patients during COVID-19 outbreak in 2020. (Table Presented)