Classification and endoscopic management of pancreatic fistulas

Figure 3 Clinical and endoscopic management considerations for pancreatic fistula. This decision-oriented schematic translates the B-P-C-A framework into endoscopic management considerations. Type B generally emphasizes conservative management, pressure reduction, and management of mature collections when needed. Type P highlights endoscopic retrograde cholangiopancreatography decompression and stent bridging when duct continuity can be restored. For Type C, “upstream duct” refers to the gland-side duct beyond the interruption, not the papilla-side segment defining C1/C2. “Open/closed” concerns upstream duct access; dilation, recanalization, bridging, and endoscopic ultrasound (EUS) guided rendezvous are conditional options in selected technically feasible cases, not routine treatment for established disconnected pancreatic duct syndrome. Short transpapillary stenting decompresses the papilla-side segment but does not drain the disconnected upstream gland. Persistent non-bridgeable leakage requires assessment for EUS-guided transmural drainage, long-term plastic stents, EUS-guided pancreatic duct drainage, EUS-guided pancreaticocutaneous fistula internalization, hybrid therapy, or surgery. Type A emphasizes postoperative anatomy, associated pancreatic fluid collection, and possible EUS-guided internal drainage or fistula internalization when conventional transpapillary bridging is unlikely. CT: Computed tomography; MRCP: Magnetic resonance cholangiopancreatography; ICU: Intensive care unit; ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Endoscopic ultrasound; PFC: Pancreatic fluid collection; WON: Walled-off necrosis; MPD: Main pancreatic duct; DPDS: Disconnected pancreatic duct syndrome; EST: Endoscopic sphincterotomy; EUS-RV: Endoscopic ultrasound-guided rendezvous.