54 - Pancreatic Interventions in Acute Pancreatitis: Ascites, Fistulae, Leaks, and Other Disruptions

Abstract

Disruptions of the pancreatic duct can be seen as a result of the significant inflammation that can occur in the setting of acute pancreatitis. Ductal disruptions result in the leakage of pancreatic fluid, which can present as myriad different clinical manifestations. The location and size of the leak are the most important factors in determining its presentation. Minor leaks will typically resolve without significant interventions, while major leaks will result in symptoms and frequently need interventions. Symptomatic pancreatic ductal leaks can cause pancreatic ascites, pleural effusions, or fluid collections. External pancreatic duct leaks are most commonly iatrogenic and frequently occur after drainage of pancreatic fluid collections. Large central duct disruptions can present as disconnected pancreatic duct syndrome. Diagnosis of pancreatic leaks is typically achieved with high-quality cross-sectional imaging or aspiration of high amylase fluid. Pancreatic leak patients are best cared for by a multidisciplinary team involving gastroenterologists, interventional radiologists, and pancreatic surgeons. Surgical interventions are now rarely needed for management of leaks because endoscopic and percutaneous interventions have improved. ERCP's main role in treatment of pancreatic leaks involves the placement of transpapillary stents that can restore the continuity of the duct. This type of therapy will often be performed in combination with transmural or percutaneous drainage of fluid collections. Efficacy of endoscopic treatments is typically very good, with reduced morbidity compared with surgical interventions.