Pancreatic duct disruption leading to pancreatic fistula (PF) or peripancreatic fluid collections (PFCs) presents a major clinical challenge. Optimal management strategies for incomplete (IPF) and complete pancreatic duct disruption (DPDS) remain controversial, and evidence regarding endoscopic treatment of non-encapsulated pancreatic leaks is limited. This study aimed to evaluate real-world outcomes of endoscopic management—including endoscopic transpapillary drainage (ETD) and EUS-guided transluminal drainage (EUS-TD)—across the spectrum of non-postoperative pancreatic duct disruption, and to compare treatment patterns and clinical outcomes between IPF and DPDS, as well as between encapsulated PFC and non-encapsulated PF.

This retrospective single-center study included consecutive non-postoperative patients with clinically significant PF or PFC secondary to pancreatic duct disruption. Only patients who underwent endoscopic treatment (ETD and/or EUS-TD) were included; cases treated solely with surgery, percutaneous catheter drainage (PCD) alone, or observation were excluded. Pancreatic duct disruption was categorized as IPF or DPDS using ERCP, imaging, and clinical course, and collections were classified as encapsulated or non-encapsulated. The primary outcome was clinical success, defined as resolution of PF/PFC-related symptoms and termination of active external drainage. Secondary outcomes included recurrence, need for PCD or surgery, and subgroup comparisons of treatment patterns.

A total of 45 patients were analyzed (IPF 37, DPDS 8; encapsulated collections 30, non-encapsulated leaks 15). Initial interventions were ETD in 31 patients (69%) and EUS-TD in 13 (29%). The modality responsible for initial improvement was ETD in 23 patients (51%) and EUS-TD in 20 (44%). Clinical success was achieved in all patients (100%). Compared with IPF, DPDS showed higher rates of recurrence (25% vs 16%), need for PCD (25% vs 14%), and surgery (13% vs 5%). Nevertheless, endoscopic treatment successfully controlled PF/PFC in 7 of 8 DPDS cases, and ETD or EUS-TD served as the final treatment in six of these. In the comparison between encapsulated PFC and non-encapsulated pancreatic fistula, treatment patterns were similar (EUS-TD: 33% vs 40%; ETD: 60% vs 60%). Recurrence (20% vs 13%), PCD requirement (13% vs 20%), and surgery (7% vs 7%) also showed no substantial differences, supporting the effectiveness of endoscopic treatment for non-encapsulated leaks. Overall, only 3 patients (7%) required surgery and 7 patients (16%) required PCD during the treatment course.

In this real-world cohort of non-postoperative pancreatic duct disruption, an endoscopic-first strategy achieved universal clinical success with low recurrence and limited surgical need. ETD and EUS-TD were effective across IPF, DPDS, encapsulated PFC, and non-encapsulated leaks. These findings support the broad applicability of endoscopic management across the full spectrum of pancreatic duct disruption.