5 Conservative therapy is aimed at decreasing endogenous pancreatic secretion so that flow through the fistula will diminish, allowing the fistula to close. However, some EPF cases are refractory to conservative treatment. Predictors of this refractoriness to conservative therapy include

low serum sodium and albumin, a high fluid-to-serum total protein ratio, and co-existence of severe chronic pancreatitis at endoscopic retrograde cholangiopancreatography.4 In patients with EPF complicating chronic pancreatitis, unfavorable anatomy of disruption, stenosis, and the narrowing of the pancreatic duct could disturb the closure of the fistula or lead to early recurrence.3,4 Surgery is considered as the next step when EPF persists for a prolonged period, despite conservative management. For instance, if the fistula has not closed within a 2–4-week trial NVP-BGJ398 molecular weight of conservative management, surgery should be considered.4 The choice of operation depends on the PS-341 purchase site of the leak and the presence of any associated pathology of the main pancreatic duct. In practice, conservative medical therapy is unsatisfactory in a significant proportion of cases, while surgical treatment is associated

with significant morbidity and mortality,6 prolonged hospitalization, and high medical costs. In these adverse situations, endoscopic intervention could be the solution for the treatment of EPF. As the experience of endoscopists has accrued and technical advances in endoscopic instruments have progressed, endotherapy for EPF can now be considered as a first-line therapeutic modality. Even with complex forms of EPF, endotherapy can be attempted instead of surgery.4,5,7–9 There are two opposite premises in endotherapy: one is that most ductal disruptions will close and heal if ductal continuity is

re-established and the pressure gradient is abolished through pancreatic sphincterotomy, stone removal, stricture dilation, and pancreatic stenting; the other is that ductal disruption might never heal without correction of the downstream obstruction.10 medchemexpress While existing data are limited to a few studies, the results of pancreatic endotherapy for EPF to date are encouraging. Kozarek et al.7,11 demonstrated a way to correct the disrupted pancreatic duct. They decompressed it by performing either a pancreatic sphincterotomy or placing a pancreatic stent; this enables the pancreatic fluid to flow into the low-pressure gut, providing an opportunity to close the leak. Instead of stent insertion, in which early stent blockage and infection could develop,7,11 nasopancreatic drainage (NPD) is preferred after sphincterotomy because the NPD can decrease the pancreatic duct pressure to levels less than those of the duodenum.12 This NPD also allows a pancreaticogram to be used to check duct patency and leaks when needed.