Our group was the first to describe the use of multiple-length stents for bridging ductal disruptions and short stents for tail leaks in this setting. Nine patients with cutaneous fistulas were included in our initial study with Paclitaxel various etiologies for their fistulas. Three patients had stents placed that bridged the site of disruption while the

other six had stents that did not bridge the disruption. Successful closure of the fistula was achieved in eight of nine patients including five within 48 hours of stent placement.[75] Since our initial description, several other series have demonstrated the effectiveness of pancreatic stents for external fistulas. Halttunen et al. described 18 patients with cutaneous pancreatic fistulas treated endoscopically. In this series, 13 patients had effective closure of the fistula. Overall published results have shown an 85% rate of successful stent placement in the setting of cutaneous fistulas, with 92% of those successfully stented achieving

closure of the fistula.[76] Pancreatic ascites has been historically managed primarily by making the patient NPO (nothing by mouth) with TPN and octreotide, with the addition of paracentesis and thoracentesis if a pleural effusion is also found. If the patient did not respond to this conservative management, a salvage operation was performed. In this setting pancreatic resections carry an 8–11% mortality, and the leaks have a 15% recurrence rate (Fig. 4).[14] Our group was the first to demonstrate that the placement of a transpapillary Cisplatin pancreatic duct stent via ERCP was an effective treatment in this setting.[77] This offers a less invasive option for treatment which is attractive given the high morbidity associated with surgical interventions. Our results have been confirmed in several other

studies.[23, 78-80] Ideally the stent is placed across the ductal disruption, but transpapillary stenting can also be effective. Endotherapy for pancreatic leaks is generally safe; however, adverse events can occur. Careful planning and high-quality cross-sectional imaging in advance of any planned intervention can help minimize problems. These complex patients are best served by multidisciplinary teams with experience and resources. Seemingly stable patients can quickly become severely ill in the event of Farnesyltransferase severe post-procedural pancreatitis or infection of a fluid collection. The most common adverse event when using endoscopy to treat pancreatic duct leak is procedure-related pancreatitis. However, other typical endoscopic complications, including drug reaction, aspiration, cardiopulmonary events, cholangitis, iatrogenic fistulas, bleeding, and perforation, can occur.[81] Pancreatitis flares approximate 10% but may approach 50% if pancreatic duct stenting is unsuccessful after multiple accessories are advanced into the pancreatic duct. However, patients with chronic calcific pancreatitis rarely experience significant post-ERCP pancreatitis.