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

Abstract

The disconnected pancreatic duct syndrome (DPDS) is a common complication of necrotizing pancreatitis. Transmural plastic stents (PS) are often left in-situ in patients with DPDS even after resolution of walled-off necrosis (WON) to allow internal diversion of the orphan pancreatic tail. Data is scarce on the long-term outcomes in these patients. Patients from our tertiary referral center were identified from an IRB approved, prospectively maintained database of WON that underwent endoscopic therapy between 2008 and 2017. DPDS was diagnosed either during endoscopic retrograde cholangiopancreatography (ERCP) or by magnetic resonance cholangiopancreatography (MRCP). Transmural stents draining WON were placed in all cases. Patients with a minimal follow-up of 6 months from endoscopic therapy were included. Ninety-six patients (70M, 26F), with a median age of 56 years (20-77) and DPDS were followed for a median of 32 months (6-114 months). 13/96 (14%) patients were treated with a lumen-apposing metal stent (LAMS) and 83/96 (86%) patients were treated with transmural PS. Fourteen patients (15%) were diagnosed with recurrent pancreatic fluid collections (PFC). Three were asymptomatic with a median size of 37mm. Eleven symptomatic PFCs, of which 8 were treated endoscopically and 3 managed conservatively, were 40mm in median size and recurred after 9 months. In 4 patients the LAMS was removed with no stent left in-situ; 1 of these patients developed a recurrent symptomatic pancreatic fluid collection (PFC). Ninety-two patients (96%) were left with transmural PS after resolution of WON. Recurrent PFCs were diagnosed in 8/35 patients in whom the PS had migrated (21%) and 5/57 patients with still indwelling PS (9%), (p=0.06). Seven surgeries (7%) were performed on these 96 patients: 3 distal pancreatectomies for chronic relapsing pancreatitis, 1 hepaticoduodenostomy for a persistent biliary stricture, 1 small bowel resection for perforation from a migrated transgastric plastic stent and 1 Roux-en-Y hepaticojejunostomy for a duodenal ampullary adenocarcinoma,. One patient died of metastatic pancreatic cancer at 52 months. An external pancreatic fistula (EPF) was diagnosed in 8 patients (8%); 7 with inability to remove percutaneous drain despite resolution of fluid collection and 1 EPF after removal of the percutaneous drain. All 8 patients were treated successfully with fistula internalization by a combined endoscopic interventional radiology procedure. Recurrent PFC in DPDS is not uncommon and seems to be more frequent when associated with stent migration, suggesting a role to possibly leave indwelling transmural stents after drainage of WON and DPDS. Recurrent PFCs and fistulae can be managed endoscopically and surgery is infrequently needed even in this subset of patients. Prospective, larger, multicenter studies are needed.