S1507 Disconnected Pancreatic Duct Syndrome: To Drain or Not to Drain?

Abstract

INTRODUCTION: Disconnected pancreatic duct syndrome (DPDS) is an uncommon complication of pancreatitis resulting in cellular necrosis and destruction of viable pancreatic tissue surrounding the duct, typically within the head or body of the pancreas. CASE DESCRIPTION/METHODS: 63-year-old male with a past history remarkable for recurrent acute necrotizing pancreatitis of unknown etiology presented with acute onset and progressively worsening abdominal pain. The patient had significant 15-year alcohol consumption history, but last ingestion was 2 years prior. He was recently discharge from a 10-day hospitalization for a previous “flare” in his pancreas that was managed conservatively. Abdominal exam is remarkable for mild to moderate tenderness throughout with moderate to severe tenderness in the epigastric and bilateral upper quadrants. Laboratory workup revealed an elevated lipase (115IU/L). CT abdomen/pelvis showed evolution of severe necrotizing pancreatitis, a large 15 cm necrotic collection replacing the pancreas neck and body, and residual enhancing pancreatic parenchymal tissue of the tail suggestive of DPDS. However, there was no fluid surrounding the disconnected pancreatic tail segment to be drained. Conservative management was recommended of the sterile necrosis as the patient was without signs of sepsis. DISCUSSION: DPDS, as the name suggests, occurs when the pancreatic duct becomes interrupted and typically occurs secondary to pancreatitis, whether that is from an acute necrotizing type, chronic relapsing type, or pancreatic fistula formation. The prevalence of this condition is unknown but estimated to occur in up to 23% of acute necrotizing pancreatitis cases. In our patient, findings of a necrotic collection replacing the pancreas neck and body with residual enhancing of the pancreatic tail was most easily seen on contrast-enhanced CT scan; however, ERCP or MRCP are other possible imaging modalities. Presence of DPDS makes the management of pancreatitis more complex and recurrence rates of DPDS can be as high as 30%. If the pancreatic duct is disrupted and there is accumulating fluid surrounding the disconnected segment of pancreas, the success rate of conservative management is usually minimal. Early pancreatic debridement or drainage is rarely helpful and is complicated by intra-abdominal hypervascularity and altered anatomy. Urgent drainage is indicated if the patient has worsening symptoms or septic signs attributable to infection of the fluid collection.Figure 1.: Contrast-enhanced computed tomography of the abdomen and pelvis demonstrating evolution of severe necrotizing pancreatitis with development of a large dominant 15 cm necrotic collection (yellow arrow) essentially replacing the pancreas neck and body. Residual enhancing pancreatic parenchymal tissue in the tail (red arrow) is highly suggestive of disconnected pancreatic duct syndrome.