Sukrit Sud

Disconnected pancreatic duct syndrome (DPDS) is a common complication of acute necrotizing pancreatitis (ANP) and may lead to persistent external pancreatic fistulae (EPFs), resulting in significant morbidity. This study evaluated the efficacy, safety, and technical variations of endoscopic ultrasound (EUS)-guided tractogastrostomy for the internalization of DPDS-related EPF. A retrospective analysis was performed on 21 patients with persistent EPF secondary to DPDS who underwent EUS-guided tractogastrostomy. Various techniques were utilized, including direct tract puncture, artificial fluid collection creation, wire localization, water instillation, double-scope technique, direct percutaneous catheter drainage (PCD) puncture, EUS-guided pancreatogastrostomy (EUS-PG), and an interventional radiologist-guided rendezvous approach. Outcomes assessed included technical success, fistula closure, complications, and follow-up data. Descriptive statistical analysis was performed to evaluate procedural outcomes, complications, and follow-up results. Technical and clinical success was achieved in all patients (100%). Complete closure of EPF was observed in all 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 recurrence were reported during the 6-month follow-up period. EUS-guided tractogastrostomy is a safe, effective, and minimally invasive technique for internalizing EPF in patients with DPDS and demonstrates promising clinical outcomes.

Introduction Between 20% and 40% of patients with severe ulcerative colitis (UC) are either steroid-refractory UC (SRUC) or steroid-dependent UC (SDUC). Tacrolimus is an oral and relatively inexpensive drug, which has been extensively used in Japan for steroid-refractory and steroid-dependent disease. Methods Patients diagnosed with SDUC/SRUC were treated with tacrolimus 0.05–0.1 mg/kg in this prospective study. Clinical Mayo score (CMS) and UC Endoscopic Index of Severity (UCEIS) were evaluated prior to starting the drug and subsequently after 8 weeks. 5-Aminosalicylic acid agents (5-ASA) and immunomodulators were continued if the patients were previously on these drugs. Clinical response at 8 weeks was defined as decrease in CMS by at least 3 points. Clinical remission was defined as CMS ≤2 and combined remission as CMS≤2 with UCEIS <3. Results Fifty-two patients (29 males) with a mean age of 35.1± 12.8 years with predominantly E3 disease (71%) were prospectively evaluated in this study. SDUC and SRUC were diagnosed in 31 and 21 patients, respectively. Seven failed treatment within 8 weeks, four were subjected to surgery, and 3 were switched to infliximab. Forty-two patients continued tacrolimus for 8 weeks. Mean CMS and UCEIS prior to starting tacrolimus were 6 ± 1.1 and 4.8 ± 1.1, respectively. At 8 weeks, median CMS and UCEIS decreased to 2.6 ± 1.7 and 2.7 ± 1.3, respectively. Clinical response was documented in 29 patients (56%) at week 8 whereas clinical remission was seen in 25 patients (48%). Combined clinical and endoscopic remissions were seen in 18 patients (35%). Except for a single patient who developed reversible renal dysfunction, no other adverse event was observed. Conclusion Our results show that tacrolimus is effective in inducing a clinical response in 56% of patients with SDUC and SRUC. In view of its low cost and safety profile, it may be considered first-line therapy for SDUC/SRUC.