Complete Disruption Of Main Pancreatic Duct Research Articles

Endoscopic transpapillary drainage for walled-off pancreatic necrosis with complete main pancreatic duct disruption by metallic stent placement: A retrospective study.

Walled-off pancreatic necrosis (WOPN) is a serious complication of acute necrotizing pancreatitis (ANP) and may lead to disruption of the main pancreatic duct (MPD). Endoscopic passive transpapillary drainage (PTD) is an effective method for treating MPD disruptions. However, WOPN with complete MPD disruption is usually accompanied by disconnected pancreatic duct syndrome (DPDS), especially with infected necrosis. Endoscopic PTD with a fully covered self-expanding metallic stent (FCSEMS) and a plastic stent placement may have the potential for future application in treating complete MPD disruption in patients with WOPN. Patients with WOPN caused by ANP were classified according to the 2012 Atlanta classification and definition. In all patients, ERCP was performed 2 times. First, 3 patients were diagnosed with complete MPD disruption by ERCP. At the time of diagnosis, a plastic pancreatic stent (7Fr) was placed. Second, they underwent endoscopic PTD for WOPN with complete MPD disruption in which an FCSEMS and plastic stent placement were the only access routes to the necrotic cavity. The etiology of pancreatitis in these patients was of biliary, lipogenic, and alcoholic origin. The WOPN lesion size ranged from 6.5 to 10.2 cm in this study, and the type of WOPN was mixed in two cases and central in one case. The type of MPD disruption was complete in all three patients. The locations of disruption included the pancreatic body and head. The time from occurrence to the first ERCP was 18, 23, and 26 days, respectively. The main symptoms were abdominal pain, abdominal distention, fever, gastrointestinal obstruction, and/or weight loss. The three patients with symptomatic WOPN and MPD disruption underwent endoscopic PTD with FCSEMS and plastic pancreatic stent placement. Technical and therapeutic successes were achieved in 3/3 of patients. The mean time of stenting was 28-93 days. The clinical symptoms connected with WOPN and collection disappeared postoperatively in all three patients. During the follow-up period of 4-18 months, no patient developed collection recurrence or other complications, such as gastrointestinal bleeding or reinfection. All patients recovered uneventfully. In patients with WOPN with complete MPD disruption, endoscopic PTD with FCSEMSs and plastic stent placement may be an effective and safe method of treatment.

Endoscopic transpapillary drainage in disconnected pancreatic duct syndrome after acute pancreatitis and trauma: long-term outcomes in 31 patients

BackgroundConventionally, disconnected pancreatic duct syndrome is treated surgically. Endoscopic management is associated with lesser morbidity and mortality than that observed with surgery and shows similar success rates. However, limited data are available in this context. We evaluated the efficacy of endotherapeutic management for this syndrome.MethodsWe prospectively obtained data of patients with disconnected pancreatic duct syndrome between September 2008 and January 2016. Demographic and clinical data were assessed, and factors affecting clinical outcomes were statistically analyzed.ResultsThirty-one patients underwent 40 endoscopic transpapillary procedures, and 1 patient developed an infection after prosthesis insertion. Etiological contributors to disconnected pancreatic duct syndrome were abdominal trauma (52%) and acute necrotizing pancreatitis (48%). The median interval between the appearance of pancreatic leaks and disconnected pancreatic duct syndrome was 6.6 months (range 0.5–84 months). The median follow-up after the last treatment procedure was 38 months (range 17–99 months). Patients with complete main pancreatic duct disruption in the body/tail showed a low risk of pancreatic atrophy (P = 0.009). This study highlighted the significant correlation between endoscopic transpapillary drainage and clinical success (P = 0.014).ConclusionsDisconnected pancreatic duct syndrome is not an uncommon sequel of pancreatic injury, and much of the delayed diagnosis is attributable to a lack of knowledge regarding this disease. Endoscopic transpapillary intervention with ductal stenting is an effective and safe treatment for this condition.

Factors and outcomes associated with pancreatic duct disruption in patients with acute necrotizing pancreatitis

Background and aimsAcute necrotizing pancreatitis (ANP) can affect main pancreatic duct (MPD) as well as parenchyma. However, the incidence and outcomes of MPD disruption has not been well studied in the setting of ANP. MethodsThis retrospective study investigated 84 of 465 patients with ANP who underwent magnetic resonance cholangiopancreatography and/or endoscopic retrograde cholangiopancreatography. The MPD disruption group was subclassified into complete and partial disruption. ResultsMPD disruption was documented in 38% (32/84) of the ANP patients. Extensive necrosis, enlarging/refractory pancreatic fluid collections (PFCs), persistence of amylase-rich output from percutaneous drainage, and amylase-rich ascites/pleural effusion were more frequently associated with MPD disruption. Hospital stay was prolonged (mean 55 vs. 29 days) and recurrence of PFCs (41% vs. 14%) was more frequent in the MPD disruption group, although mortality did not differ between ANP patients with and without MPD disruption. Subgroup analysis between complete disruption (n = 14) and partial disruption (n = 18) revealed a more frequent association of extensive necrosis and full-thickness glandular necrosis with complete disruption. The success rate of endoscopic transpapillary pancreatic stenting across the stricture site was lower in complete disruption (20% vs. 92%). Patients with complete MPD disruption also showed a high rate of PFC recurrence (71% vs. 17%) and required surgery more often (43% vs. 6%). ConclusionsMPD disruption is not uncommon in patients with ANP with clinical suspicion on ductal disruption. Associated MPD disruption may influence morbidity, but not mortality of patients with ANP. Complete MPD disruption is often treated by surgery, whereas partial MPD disruption can be managed successfully with endoscopic transpapillary stenting and/or transmural drainage. Further prospective studies are needed to study these items.

Complete disruption of the main pancreatic duct: Endoscopic management

Background: Complete disruption of the main pancreatic duct is an unusual event in the course of acute or chronic pancreatitis. Endoscopic management has already proven effective in the treatment of partial ruptures. Methods: Thirteen patients presented over a 7-year period with acute (9 patients) or chronic (4 patients) pancreatitis complicated by complete disruption of the main pancreatic duct and cyst formation. Endoscopic treatment was attempted in 12. Treatment varied depending on the site of the rupture and accessibility of the pseudocyst and consisted either of transpapillary drainage (3), cystogastrostomy (3), cystoduodenostomy (2), or combined procedures (4) when one of these procedures did not induce significant decrease in collection size. Long-term results were obtained by observing the patients with ultrasound, CT, ERCP, and clinical evaluation. Results: Short-term results were excellent with complete cyst resolution and clinical recovery in all but one patient treated by endoscopy. Two patients had pseudocyst infection successfully treated by drainage and antibiotics. Long-term follow-up was available for 11 patients (mean duration, 30.2 months; range, 12 to 72 months) without relapsing clinical symptoms or pseudocyst. Conclusions: Endoscopic management is effective and safe for treating patients with complete main pancreatic duct disruption. A double drainage combining transpapillary drainage and cystoenterostomy must be done in selected instances, especially when rupture occurs in the setting of chronic pancreatitis with stricture or stone distal to the rupture. (Gastrointest Endosc 1995;42:445-51.)