Tractogastrostomy: A Case Series and Review of Novel Endoscopic Ultrasound-Guided Modality for Internalization of the External Pancreatic Fistula in the Disconnected Pancreatic Duct Syndrome

Abstract Disconnected pancreatic duct syndrome (DPDS) often complicates acute necrotizing pancreatitis (ANP) and can result in persistent external pancreatic fistulae (EPFs), leading to significant morbidity. Traditional surgical approaches are effective, but are associated with a high risk. Endoscopic ultrasound (EUS)-guided tractogastrostomy has emerged as a minimally invasive technique to internalize EPF by creating a physiological drainage route into the stomach. This study evaluated the efficacy, safety, and technical variations of EUS-guided tractogastrostomy for DPDS-related EPF. We retrospectively analyzed 21 patients with persistent EPF secondary to DPDS who underwent EUS-guided tractogastrostomy using different techniques: Direct tract puncture, artificial fluid collection creation, wire localization, water instillation, double-scope, direct percutaneous catheter drainage (PCD) puncture, EUS-guided pancreatogastrostomy (EUS-PG), and interventional radiologist-guided rendezvous approach. The outcomes included technical success, fistula closure, complications, and follow-up data. Technical and clinical success was achieved in all patients (100%). Complete EPF closure occurred in all the patients within 3 months. Minor complications included abdominal pain (n = 4), minor bleeding (n = 1), and stent migration (n = 3, 14.28%). No major adverse events or recurrences were reported over the 6-month follow-up period. EUS-guided tractogastrostomy is a safe, effective, and minimally invasive procedure for internalizing EPF in DPDS with promising clinical outcomes.