Resolving external pancreatic fistulas in patients with disconnected pancreatic duct syndrome: using rendezvous techniques to avoid surgery (with video)

Tu1395 LONG TERM FOLLOW-UP OF PATIENTS WITH A DISCONNECTED PANCREATIC DUCT FOLLOWING TREATMENT OF WALLED-OFF NECROSIS

Su1711 Management of Pancreatic Ductal Leaks in Patients With Chronic Pancreatitis

Purpose: Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aim to review the definitions, clinical presentation, intervention, and outcomes for DPDS. Method: The PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites. Results: Thirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.3%, 936/982), followed by chronic pancreatitis (3.1%, 30/982). DPDS commonly presented with PFC (83.2%, 948/1140) and EPF (13.4%, 153/1140). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI 81.0-95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7-77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6-90.5) and 87.4% (95%-CI 81.2-91.8), respectively (P=0.389). Conclusion: Endoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research.

Roux-en-Y fistulojejunostomy as a salvage procedure for displaced pancreatic stent in disconnected pancreatic duct syndrome with refractory external pancreatic fistula

Walled-off pancreatic necrosis resulting from severe necrotizing pancreatitis often leads to complications, including disconnected pancreatic duct syndrome (DPDS) and the subsequent development of external pancreatic fistulas (EPFs). This study aimed to evaluate the long-term outcome of rendezvous internalization treatment for EPF associated with DPDS. A retrospective review of 40 patients with EPFs secondary to DPDS who underwent rendezvous treatment between October 2008 and October 2023 was conducted. Three techniques were utilized: outside-in (n = 18), inside-out (n = 19), and pancreatic duct bridging (n = 3). Primary outcomes included the rate of surgery post-treatment, while secondary outcomes encompassed recurrence of peripancreatic fluid collection (PFC) or EPF. The mean age of patients was 54.6years, with 67.5% being male. Gallstones (37.5%) and alcohol (25.0%) were the leading etiologies. The median time from pancreatitis onset to the procedure was 216days. All patients achieved EPF closure, with a median closure time of 20days. Procedure-related complications included post-procedural acute pancreatitis (12.5%) and minor bleeding (7.5%), with no perforations or mortality. During a median follow-up of 53.5months, recurrence of EPF occurred in three patients (7.5%), with two requiring surgery (5.0%). Recurrence of PFC (22.5%) and acute pancreatitis (17.5%) were also observed. New-onset diabetes mellitus occurred in 50% of patients. Rendezvous internalization treatments are highly effective for EPFs associated with DPDS, achieving high closure rates and low recurrence. These findings underscore their potential to reduce surgical necessity. Prospective studies are warranted to optimize strategies for these challenging cases.

Background Long-term indwelling transmural stents in patients with walled-off pancreatic necrosis (WOPN) and disconnected pancreatic duct syndrome (DPDS) has been accepted as an effective strategy to decrease the risk of recurrence of pancreatic fluid collection (PFC). However, long term studies on the safety and efficacy of leaving permanent indwelling plastic prosthesis are lacking. Methods Retrospective analysis of the database of patients with WOPN treated with endoscopic transmural drainage over the last 8 years was done to identify patients with DPDS and permanently intended indwelling transmural stents. Patients with indwelling stents for more than 3 years were only included in this study. The follow-up database was analysed for any recurrence of symptoms or PFC or complications. Results During the last 8 years, 179 patients of WOPN were treated with endoscopic transmural drainage and 138 (77.09%) patients had DPDS. Of 138 patients, 56 patients (39 males; age range: 21–62 years) had an indwelling transmural stent/stents for >3 years (3–8 years). Amongst plastic prosthesis, 67.85% of patients had 10 Fr stents and 32.14% of patients had 7 Fr stents. Neck (n=28; 50%) was the most common site of disruption followed by proximal body (n=16; 28.57%) and distal body (n= 12; 21.43%). One patient (1.78%) developed recurrence of fluid collection 58 months later despite of in-situ stent which was successfully treated with repeat endoscopic transmural drainage. Two (3.5%) patients had asymptomatic spontaneous external migration of the transmural stent. Two (3.5%) patients developed complications 4 years later because of the indwelling stent. The transmural stent eroded into descending colon in one patient and the other patient had a recurrence of abdominal pain due to the development of pancreatic parenchymal calcification around the pigtail of the plastic stent. The transmural stent was removed in both patients and this led to the closure of colonic fistula as well cessation of abdominal pain. No other complication of long term indwelling transmural stents was observed. Conclusions Long term indwelling transmural stents in patients with WOPN and DPDS are safe as well as effective in preventing recurrence of PFC.

Endoscopic intervention for pancreatic fluid collections (PFCs) with disconnected pancreatic duct syndrome (DPDS) has been associated with failures and increased need for additional endoscopic and non-endoscopic interventions. The primary aim of this study was to determine the outcomes of endoscopic ultrasound (EUS)-guided transmural drainage of PFCs in patients with DPDS. In patients undergoing EUS-guided drainage of PFCs from January 2013 to January 2018, demographic profiles, procedural indications and details, adverse events, outcomes, and subsequent interventions were retrospectively collected. Overall treatment success was determined by PFC resolution on follow-up imaging or stent removal without recurrence. EUS-guided drainage of PFCs was performed in 141 patients. DPDS was present in 57 of them (40 %) and walled-off necrosis was the most frequent type of PFC (55 %). DPDS was not associated with lower clinical success, increased number of repeat interventions, or increased time to PFC resolution. Patients with DPDS were more likely to be treated with permanent transmural plastic double-pigtail stents (odds ratio [OR] 6.4; 95 % confidence interval [CI] 2.5 - 16.5; P < 0.001). However, when stents were removed, DPDS was associated with increased PFC recurrence after stent removal (OR 8.0; 95 %CI 1.2 - 381.8; P = 0.04). DPDS frequently occurs in patients with PFCs but does not negatively impact successful resolution. DPDS is associated with increased PFC recurrence after stent removal.

Longterm outcome of rendezvous technique for hepaticojejunal anastomotic obstruction after pediatric living donor liver transplantation.

Consequences of long term indwelling transmural stents in patients with walled off pancreatic necrosis & disconnected pancreatic duct syndrome

Background and Objectives:Long-term indwelling transmural stents in patients with walled off pancreatic necrosis (WOPN) and disconnected pancreatic duct syndrome (DPDS) decreases risk of recurrence of pancreatic fluid collection (PFC). However, stents can spontaneously migrate causing recurrence of PFC in some patients whereas some patients may have asymptomatic migration of stents. We aim to retrospectively evaluate profile of patients with recurrent PFC following migration of transmural stents in patients with WOPN and DPDS and compare it with patients who had asymptomatic migration of stents.Patients and Methods:Records of consecutive patients who underwent endoscopic transmural drainage of WOPN over last 4 years were analyzed and patients with DPDS identified. Results: Thirty-five patients (29 M; mean age 37.0 ± 7.6 years) were followed-up for mean of 28.2 ± 14.0 months (range: 6–50 months). Eight patients (22.8%) had spontaneous migration of stents. It led to recurrence of PFC in three patients, whereas in five patients it was asymptomatic. The patients with recurrent PFC had early stent migration (2, 4, and 5 months respectively) whereas patients with asymptomatic migration had their stents migrating >6 months of resolution. Patients with recurrent PFC had duct disruption in pancreatic head (100% vs. 20%), and low frequency of diabetes (nil vs. 40%), steatorrhea (nil vs. 20%) as well as pancreatic atrophy (nil vs. 80%).Conclusion:Early migration of stents, ductal disruption in pancreatic head as well as absence of diabetes, steatorrhea, and pancreatic atrophy seem to increase risk of recurrent PFC following migration of transmural stents in patients with DPDS.

Disconnected pancreatic duct syndrome in severe acute pancreatitis: clinical and imaging characteristics and outcomes in a cohort of 31 cases

Importance of Disconnected Pancreatic Duct Syndrome in Recurrence of Pancreatic Fluid Collections Initially Drained Using Lumen-Apposing Metal Stents

To study the effect of disconnected pancreatic duct syndrome (DPDS) on endoscopic management of pancreatic fluid collections (PFCs). Data on the impact of DPDS in patients undergoing endoscopic treatment of PFCs are limited. Retrospective study of patients undergoing endoscopic drainage of PFCs from 2003 to 2015. If treatment response was suboptimal following initial endoscopic or endoscopic ultrasound-guided transmural drainage, hybrid interventions (endoscopic ultrasound-guided multigate/dual modality technique, endoscopic/percutaneous sinus tract necrosectomy) were performed. Transmural stents were left permanently in situ in DPDS patients from 2008 onwards. Main outcome measures were to evaluate the effect of DPDS on need for hybrid treatment, reinterventions, rescue surgery, length of stay, and overall treatment success. Of 361 patients, 34 (9.4%) were acute collections, 178 (49.3%) pseudocysts, and 149 (41.3%) walled-off necrosis (WON). DPDS was present in 167 (46.3%) patients, absent in 124 (34.3%), unknown in 70 (19.4%), and occurred more frequently in WON compared to other PFCs (68.3% vs 31.7%; P < 0.001). Although there was no difference in treatment success, more patients with DPDS required hybrid treatment (31.1% vs 4.8%, P < 0.001), reinterventions (30% vs 18.5%, P = 0.03), rescue-surgery (13.2% vs 4.8%, P = 0.02), and longer length of stay [median (interquartile range) days, 3 (2-10) vs 2 (1-4), P = 0.003]. PFC recurrence was lower in patients with DPDS with permanent transmural stents (17.4% vs 1.7%, P < 0.001). On multivariate logistic regression, DPDS [odds ratio (OR) 2.99], WON (OR 3.37), PFC size of 100 mm or more (OR 2.66), and multiple PFCs (OR 10.6) were associated with need for hybrid treatment. DPDS has a significant effect on endoscopic management of PFCs as more patients required hybrid treatment, reinterventions, and rescue surgery for achieving optimal clinical outcomes.

Natural course of low output external pancreatic fistula in patients with disconnected pancreatic duct syndrome following acute necrotising pancreatitis

Introduction: Ruptured walled of pancreatic necrosis (WOPN) with disconnected pancreatic duct syndrome (DPDS) is a rare condition. WOPN can rupture in gastrointesinal tract or in the peritoneal cavity. Rupture of WOPN into the peritoneal cavity is difficult to treat and has dilemmas in management approach, it also has high possibilities of infections, pancreatic fistulas and carries high mortality. Methods: We present a case series of 8 patients of acute necrotizing pancreatitis with disconnected pancreatic duct syndrome (DPDS) and walled off pancreatic necrosis (WOPN) with spontaneous rupture. Results: Two patients had rupture into the GI tract (1 in the antrum and 1 in 1st part of duodeum). 2 plastic stents were placed through the luminal opening into the pseudocyst cavity to create an internal fistula and later underwent ERCP with pancreatic duct (PD) stenting. 6 patient had a rupture in the perinoteal cavity causing pancreatic peritonitis. Ascitis was aspirated for diagnosis with ascitic amylase ranging from 8945 to 25768 U/L. All patients presented with high grade fever and systemic inflammatory response syndrome (SIRS). The average size of the WOPN was 8 cms with wall thickness of 4 mm. Surgical gastrocystostomy was not possible.5 patients underwent endoscopic ultrasound guided gastrocystostomy with lumen opposing metal stent (LAMS) to drain the WOPN and create an internal fistula,followed by ERCP with PD stenting. 3 patients had clear ascitic fluid so were drained by percutaneous pigtail drainage. 2 patients had multiple internal septations in the ascitic fluid, hence were later subjected to a laparotomy with peritoneal lavage and external drain placement. One patient had a complete rupture of the WOPN with no residual collection, hence only PD stent followed by peritoneal lavage was done. All patients were on broad spectrum antibiotics and nasojejunal feeds.None of patients required endoscopic pancreatic necrosectomy. There was no mortality, no external pancreatic fistula and the average hospital stay was 10 days. Conclusion: This is the first case series of 8 patients with partially ruptured WOPN managed successfully.Figure 1.: Partially ruptured WOPN with Pancreatic ascites.