Endoscopic Use of N-Butyl-2-Cyanoacrylate in Refractory Pancreatic Duct Leak and Cystic Duct Leak: Is It Really a Last Resort?

Abstract

Background/Objectives: The management of refractory pancreatic duct (PD) and cystic duct leaks may represent an endoscopic challenge. Standard endoscopic therapy involves pancreatic/biliary sphincterotomy and stenting during endoscopic retrograde cholangiopancreatography (ERCP). After conservative (fasting, parenteral nutrition, and use of somatostatin analogs) or conventional endoscopic treatments fail, a surgical approach is usually required, leading to higher mortality due to several technical complications. Previous evidence of the endoscopic use of N-butyl-2-cyanoacylate (NBCA) for treating pancreaticobiliary leaks is reported, although the evidence is scarce. Methods: Six patients with pancreaticobiliary leaks (three IT pancreatic leaks and three Class A sec. Strasberg post-cholecystectomy biliary leaks) refractory to previous treatment were treated with the endoscopic topical application of NBCA. All our patients gave informed consent. The procedures were all performed between December 2017 and February 2025 at a tertiary referral center for biliopancreatic endoscopy. Results: Therapeutic success, as shown both endoscopically and radiologically, was 100%, and no procedural complication was reported. In one patient with biliary leak, standard cannulation of the cystic duct stump with the guidewire was unsuccessful, requiring a peroral cholangioscopy (SpyGlass System DSII) to directly visualize the leakage site, allowing a precise closure of the wall defect with NBCA. Conclusions: NBCA injection could represent a safe and effective endoscopic option in refractory PD of the tail of the pancreas and cystic duct leaks. Larger and further studies are necessary to confirm these results.

Keywords: N-butyl-2-cyanoacrylate; cystic duct leak; endoscopic retrograde cholangiopancreatography; pancreatic duct leak.

Figure 1

(A) Fluoroscopic image of a PD disruption at the tail level with extravasation of contrast medium. (B) Evidence of the leak resolution after injection of N-Butyl-2-Cyanoacrylate.

Figure 2

(A) Fluoroscopic image of a cystic duct leak with extravasation of contrast medium; (B) cholangioscopic view of the leak; (C) evidence of the leak resolution after injection of N-Butyl-2-Cyanoacrylate.