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) 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.