Théophile Guilbaud, François Portier, Marie Pierre Mathoulin-Portier, Yves Rinaldi, Régis Fara
Context Fistula formation between the pancreas and adjacent organs has been reported in up to 6.6% of Intraductal papillary mucinous neoplasm cases of the pancreas. Pancreaticobiliary fistulas connect the intrapancreatic portion of the common bile duct and the main pancreatic duct. Case report Herein we report a case of an eighty-year-old man presented with a main pancreatic duct - intraductal papillary mucinous neoplasm complicated by PB fistula and obstructive cholangitis caused by the impaction of thick mucus protruding from the pancreas into the bile duct. In the present case, the main difficulty was the control of sepsis and jaundice related to the PB fistula. Endoscopic retrograde cholangiopancreatography was undertaken to confirm pancreaticobiliary fistulas and perform common bile duct drainage. Thick mucus flowing from the papilla revealed “pig-nose” appearance. Three endoscopic procedures were required because of failure to obtain effective common bile duct drainage due to stent migration and obstruction. Eventually a large covered biliary metallic stent was positioned to treat recurrent obstructive cholangitis. Combined with prolonged antibiotherapy these manoeuvres allowed biliary sepsis control, but jaundice persisted. A surgical approach was then decided to treat both persistent obstructive jaundice and the intraductal papillary mucinous neoplasm. Conclusion Pancreaticobiliary fistulas fistula presenting as jaundice and /or cholangitis is a rare condition and is associated with malignancy in half of the patients. Biliary stenting remains the first line treatment but fails to control symptoms in half of the cases. Under such circumstances resective surgery is a radical treatment that resolves both the symptoms and the cause of PB fistula and should not be delayed.
