Disconnected Pancreatic Duct Syndrome Research Articles

THE ROLE OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY FOR PREVENTING PANCREATIC FLUID COLLECTION RECURRENCE AFTER EUS-GUIDED DRAINAGE OF WALLED-OFF NECROSIS

Pancreatic fluid collections (PFC) may recur after initial successful endoscopic drainage of walled-off necrosis (WON), most commonly due to disconnected pancreatic duct syndrome (DPDS). The primary aim of this study is to assess the role of magnetic resonance cholangiopancreatography (MRCP) for identifying DPDS to guide appropriate management and prevent PFC recurrence. Patients with WON undergoing LAMS drainage of a PFC were retrospectively identified and categorized as those with versus those without MRCP prior to removal of transmural stents. Data on patient demographics, procedural details, cross-sectional imaging, and recurrence rates were collected through chart review. A total of 121 patients with WON were identified, of whom 44 (36.4%) had an MRCP prior to transmural stent removal. In patients without MRCP, 13/77 (16.8%) had PFC recurrence versus 0/44 (0%; p=0.003) in those with MRCP. MRCP identified DPDS in 12 (27.2%) patients, all of whom were managed with indefinite drainage with double-pigtail plastic stents (DPPS) without recurrence. In the group without MRCP, PFCs recurred at a median interval of 284 days (IQR 182-618 days) after transmural stent removal. Among the 13 patients with PFC recurrence, 11 patients (85%) had undiagnosed DPDS detected on subsequent imaging, of whom 9 were subsequently managed with indefinite DPPS, without further PFC recurrence. Patients with WON who underwent MRCP prior to transmural stent removal had a lower rate of PFC recurrence largely due to the identification of DPD with appropriate endoscopic management.

Multicenter study of the efficacy and safety of electrocautery-enhanced lumen-apposing metal stents for the internal drainage of pancreatic fluid collections

Pancreatic fluid collections (PFCs) including pancreatic pseudocyst (PP) and walled-off necrosis (WON) are complications after acute pancreatitis. We aimed to evaluate the efficacy and safety of endoscopic ultrasound (EUS)-guided lumen-apposing metal stent (LAMS) placement to manage PFCs. Between June 2019 and May 2023, patients with symptomatic PFCs who underwent EUS-guided electrocautery-enhanced LAMS drainage were enrolled retrospectively from eight tertiary centers in Taiwan. In total, 33 [14 (42.42%) PP and 19 (57.58%) WON] patients were enrolled. Gallstones (27.27%) and abdominal pain (72.73%) were the most common etiology and indication for drainage. The technical and clinical success rates were 100% and 96.97%, respectively, and the mean procedure time was 30.55 (± 16.17) min. Complications included one (3.03%) case of self-limited bleeding; there were no cases of mortality. Seven (21.21%) patients had recurrence. Patients with disconnected pancreatic duct syndrome (DPDS) had a higher recurrence rate than those without (71.43% vs. 38.46%, p = 0.05). After replacing LAMSs with transmural double-pigtail plastic stents (DPSs) in the DPDS patients, the DPS migration rate was higher in the patients with recurrence (100% vs. 33.33%, p = 0.04). In conclusion, drainage of symptomatic PFCs with EUS-guided electrocautery-enhanced LAMS appears to be efficient and safe. Replacing LAMSs with DPSs in DPDS patients was associated with a lower recurrence rate.

DPDS Demystified: Imaging Insights and Minimally Invasive Management

Abstract Aim This article retrospectively evaluates the radiological imaging features in establishing the diagnosis of pancreatic duct disconnection along with outlining the effective management protocols. Materials and Methods Sixty-three patients with radiological or clinical suspicion of pancreatic duct disconnection were identified. Their computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) images, clinical data, and laboratory parameters from medical records were retrieved and analyzed. Endoscopic retrograde cholangiopancreatography (ERCP) findings or raised amylase values in the necrotic collection higher than three times the reference range were considered as proven cases of disconnected pancreatic duct syndrome (DPDS) for the study. Multiple parameters were assessed on imaging to establish the diagnosis of DPDS. SPSS software was used for statistical analysis and radiological imaging features of pancreatic duct disconnection were evaluated. Laboratory parameters of serum amylase/lipase and amylase/lipase values from the collection were also studied along with the mode of clinical management and outcome on follow-up. Results The radiological imaging features of pancreatic duct disconnection were assessed in 63 patients in which it was seen that magnetic resonance imaging had a significantly higher accuracy rate in diagnosing DPDS as opposed to CT. Minimally invasive procedures such as endoscopic cystogastrostomy was the preferred management in most cases with ERCP stenting being the next favored management of choice. Resolution or reduction of symptoms was mostly seen on follow-up with 12.69% of patients developing complications. Conclusion This study highlighted the imaging features of DPDS apart from ascertaining the parameters that could be assessed to aid in early diagnosis of DPDS. MRCP has a higher accuracy rate compared with CT in diagnosing DPDS. A combination of two or more parameters on MRCP was more accurate in the identification of DPDS rather than a single parameter. Minimally invasive treatment options such as endoscopic transluminal drainage with or without stenting are currently preferred in the treatment of DPDS over surgical management. Early diagnosis and prompt management of DPDS is essential to reduce the onset of serious complications apart from improving the quality of life of these patients posttreatment.

A novel peroral pancreatoscopy combined endoscopic ultrasonography-assisted rendezvous procedure: a new strategy for bridging disconnected pancreatic duct syndrome.

A novel peroral pancreatoscopy combined endoscopic ultrasonography-assisted rendezvous procedure: a new strategy for bridging disconnected pancreatic duct syndrome.

Endoscopic management of pancreatic fluid collections with disconnected pancreatic duct syndrome.

Disconnected pancreatic duct syndrome (DPDS) is an important and common complication of acute necrotizing pancreatitis. Endoscopic approach has been established as the first-line treatment for pancreatic fluid collections (PFCs) with less invasion and satisfactory outcome. However, the presence of DPDS significantly complicates the management of PFC; besides, there is no standardized treatment for DPDS. The diagnosis of DPDS presents the first step of management, which can be preliminarily established by imaging methods including contrast-enhanced computed tomography, ERCP, magnetic resonance cholangiopancreatography (MRCP), and EUS. Historically, ERCP is considered as the gold standard for the diagnosis of DPDS, and secretin-enhanced MRCP is recommended as an appropriate diagnostic method in existing guidelines. With the development of endoscopic techniques and accessories, the endoscopic approach, mainly including transpapillary and transmural drainage, has been developed as the preferred treatment over percutaneous drainage and surgery for the management of PFC with DPDS. Many studies concerning various endoscopic treatment strategies have been published, especially in the recent 5 years. Nonetheless, existing current literature has reported inconsistent and confusing results. In this article, the latest evidence is summarized to explore the optimal endoscopic management of PFC with DPDS.

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.

Disconnected pancreatic duct syndrome in patients with necrotizing pancreatitis

In a subset of patients with acute necrotizing pancreatitis, segmental necrosis affecting the main pancreatic duct may result in a discontinuity between the left-sided pancreas and the duodenum. Such an interruption in the setting of a viable upstream portion of the gland can give rise to the disconnected pancreatic duct syndrome (DPDS). By maintaining its secretory function, the disconnected segment may lead to persistent external pancreatic fistulae, recurrent pancreatic fluid collections, and/or obstructive recurrent acute or chronic pancreatitis of the isolated parenchyma. There are currently no universally accepted guidelines for the diagnosis or treatment of DPDS, and because the condition is underrecognized, the diagnosis is often delayed. DPDS is associated with a prolonged disease course and poses a burden on patients' quality of life as well as high health care resource utilization. The aim of our review is to summarize current knowledge, discuss diagnostic approaches, outline management options, and raise awareness of this challenging complication of necrotizing pancreatitis.

A release from WONderland: endoscopic ultrasonography-guided reconnection of disconnected pancreatic ducts across a walled-off necrosis cavity.

Disconnected pancreatic duct syndrome (DPDS) in cases with walled-off necrosis (WON) is associated with recurrence of pancreatic fluid collection [1] and new-onset diabetes [2]. Transpapillary stent placement across disconnected pancreas has been attempted but the technical success rate of this procedure is low [3] [4].

S1798 Pancreatic Duct Injury Secondary to Pancreatic Trauma Successfully Treated With Transgastric Pancreatic Drainage

Introduction: Disconnected pancreatic duct syndrome (DPDS) is an underrecognized complication of pancreatic trauma and acute pancreatitis. DPDS is characterized by a disruption of the main pancreatic duct. Its diagnosis is confirmed by either MR cholangiopancreatography (MRCP) or retrograde cholangiopancreatography (ERCP). In this case, we present a patient who developed DPDS secondary to blunt abdominal trauma, successfully treated with a transgastric pancreatic drainage. Case Description/Methods: A 36-year-old female with a medical history of renal dysplasia and chronic kidney disease stage V arrived at our institution after presenting with epigastric abdominal pain, nausea, and early satiety of a week of evolution. The patient was recently discharged from a trauma center after being admitted for 2 weeks after a domestic violence incident involving blunt abdominal trauma. Upon initial evaluation, the abdominal exam was remarkable for tenderness in the epigastric area upon deep palpation. Laboratory were remarkable for elevated renal parameters and severely elevated pancreatic enzymes. Initial Abdominopelvic CT showed pancreatic transection across the head and neck pancreatic junction, with an associated fluid collection consistent pancreatic fluid extravasation. MRCP was performed, which confirmed the pancreatic transection with an associated pseudocyst at the pancreatic genu consistent with disconnect pancreatic duct syndrome. After interdisciplinary evaluation, an endoscopic ultrasound-guided cystgastrostomy stent was placed. After the procedure, the patient significantly improved symptoms and was discharged 2 days later. The patient was re-evaluated 2 weeks later with a CT scan, which showed transgastric pancreatic drainage with complete resolution of peripancreatic fluid collection. Transgastric pancreatic drainage was removed 2 months later. Follow up Ct scan done 2 months after stent removal showed normal anatomy of the pancreas with no distinct inflammatory tissue reaction and no evidence of peripancreatic collection. Discussion: Pancreatic ductal injury after trauma is mainly managed surgically but may result in high morbidity and mortality. Advances in endoscopy have allowed minimally invasive interventions as an alternative that can be performed in dstan effective and safe manner.

S1675 Blame It on the Bamboo Stump: A Pancreatic Ductal Disruption Successfully Managed With Two-Step Endoscopic Therapy

Introduction: Non-penetrating, isolated pancreatic injuries are rare, and the management is not well-established and challenging. Most injuries are managed by surgery, but recently several case reports discuss endoscopic therapy for treatment of main pancreatic duct disruption. We report a case of pancreatic injury from falling on a bamboo stump with complete pancreatic ductal disruption and complete pancreas divisum with a dominant dorsal duct that was successfully nonoperatively managed through endoscopic therapy. Case Description/Methods: An 18-year-old male transferred for worsening abdominal pain from a grade IV pancreatic injury complicated by pancreatic ascites and massive pancreatic fluid collections (PFCs) sustained a month prior after a non-penetrating fall onto a bamboo rod in the Caribbean. He had failed conservative therapy and 2 attempts with ERCP for pancreatic duct (PD) stent placement. CT A/P and MRCP showed a 13cm cyst consistent with hemorrhagic pancreatic pseudocyst (Figure A-B). Labs showed leukocytosis, elevated lipase and LFTs, but he was hemodynamically stable. US-guided paracentesis drained 250mL of fluid consistent with pancreatic ascites. To allow for pancreatic edema reduction, we elected for a 2-step procedure with separate EUS and ERCP. EUS showed multiple PFCs s/P endoscopic cyst-gastrostomy with Axios stent (Figure C-D). Repeat CT A/P showed decrease in size of the PFCs (Figure E). He was discharged and returned in one week for ERCP that revealed a surprising complete pancreas divisum and total disrupted main dorsal PD, which was endoscopically treated with sphincterotomy of the minor papilla and a long PD stent across the disruption (Figure F-H). The Axios stent was removed a week later, and 4 weeks later we successfully removed the PD stents from both the major and minor papillae. He made an uneventful recovery and remains well. Discussion: Pancreatic disruption syndrome or Disconnected Pancreatic Duct Syndrome (DPDS) is an interruption of pancreatic duct continuity, usually from necrotizing pancreatitis, but can occur with blunt or penetrating abdominal injury, as in our patient. Endoscopic management is a minimally invasive option for DPDS and pancreatic ascites. Our patient had severe pancreatic injury managed using 2-stage endoscopic therapy, demonstrating a successful treatment strategy for pancreatic injury with total main DPDS. Further studies are required regarding the selection of patients, safety, and long-term outcomes.Figure 1.: Image A: CT A/P (coronal) demonstrating edematous pancreas with significant peripancreatic fat stranding, with a peripherally enhancing hypodense fluid collection near the body and tail of the pancreas measuring approximately 4.0 x 4.8 x 13 cm in the maximum AP, RL and SI dimensions (red arrow). Image B: MRCP (coronal) Abutting the pancreatic body is a multilobulated rim-enhancing complex fluid collection that extends from the level of the diaphragmatic hiatus to just above the level of the aortoiliac bifurcation and measures 6.8 x 9.7 x 19.1 cm (AP by TR by SI, red arrow). Image C-D: EUS demonstrating large pancreatic fluid collection (PFC, left) and s/P Axios cyst-gastrostomy (right). Image E: CT A/P (coronal) demonstrating cyst-gastrostomy placement with interval decrease in PFC. Image F-H: Pancreatogram showed extravastion of contrast material at the junction of proximal 2/3 and distal1/3 of the dorsal PD c/w disrupted dorsal PD (Complete Pancreas divisum, left). Placement of a 5 Fr 9 cm Zimmon PD stent with pigtail crossing the disruption at the minor papilla (center). Pancreatogram showing no extravasation of contrast material s/P PD stent placement.

Long-term transmural drainage of pancreatic fluid collections with double pigtail stents following lumen-apposing metal stent placement improves recurrence-free survival in disconnected pancreatic duct syndrome.

Disconnected pancreatic duct syndrome (DPDS) is the most common cause of pancreatic fluid collection (PFC) recurrence. While long-term transmural drainage with plastic stents is the preferred endoscopic approach, there is a paucity of literature on patients undergoing initial drainage with lumen-apposing metal stents (LAMS). We describe our experience managing patients with DPDS. A retrospective review of a prospectively maintained database (November 2015-September 2020) was performed looking at clinical outcomes and overall survival for patients undergoing endoscopic management of PFCs using LAMS. The primary outcome was to assess recurrence-free survival in PFC patients with DPDS managed with or without double pigtail stents (DPS) replacement after LAMS removal. Of 96 patients with PFCs, 48 with DPDS were included in the study. The median follow-up was 20.1 months. LAMS replacement with DPS was successful in 21/48 (43.8%) patients. Recurrence was seen in 1/21 (5%) patients with DPS replacement and 10/27 (37%) without DPS replacement. In multivariable models, a longer duration of LAMS placement was negatively associated with successful DPS replacement (odds ratio 1.33, 95% confidence interval [CI] 1.11, 1.59, P = 0.0019) and successful LAMS replacement with DPS in patients with DPDS improved recurrence-free survival (hazard ratio 0.09, 95% CI 0.01, 0.83, P = 0.033). In patients with PFCs and DPDS, early replacement of LAMS with DPS improves the likelihood of successful long-term transmural drainage and decreases recurrences.

Disconnected Pancreatic Duct Syndrome: Pancreatitis of the Disconnected Pancreas and Its Role in the Development of Diabetes Mellitus.

INTRODUCTION:Disconnected pancreatic duct syndrome (DPDS) is a recognized complication of necrotizing pancreatitis (NP). Manifestations include recurrent peripancreatic fluid collections (R-PFC) and pancreatocutaneous fistulae (PC-Fistulae). Pancreatitis of the disconnected pancreatic segment (DPDS-P) and its relationship to new-onset diabetes after pancreatitis (NODAP) are not well characterized.METHODS:We performed a retrospective cohort study of consecutive patients with NP admitted to University of California, San Francisco from January 2011 to June 2019. A diagnosis of a disconnected pancreatic duct (PD) was confirmed using computed tomography and magnetic resonance cholangiopancreatography/endoscopic retrograde cholangiopancreatography. DPDS was defined as a disconnected PD presenting with R-PFC, PC-Fistulae, or DPDS-P. The primary outcome was NODAP, defined as diabetes mellitus (DM) occurring >3 months after NP. Cox proportional hazards regression was used to evaluate the relationship between DPDS and NODAP.RESULTS:Of 171 patients with NP in this study, the mean clinical follow-up was 46 ± 18 months and the imaging follow-up was 38 ± 20 months. Twenty-seven patients (16%) developed DPDS-P at a median of 28 months. New-onset DM occurred in 54 of the 148 patients (36%), with 22% developing DM within 3 months of NP and 14% developing NODAP at a median of 31 months after AP. DPDS-P was associated with NODAP when compared with non-DPDS patients (adjusted hazard ratio 5.63 95% confidence interval: 1.69–18.74, P = 0.005) while R-PFCs and PC-Fistulae were not.DISCUSSION:DPDS and NODAP occurred in 28% and 14% of the patients, respectively. Pancreatitis of the disconnected pancreas occurred in 16% of the patients and was associated with higher rates of NODAP when compared with patients with other manifestations of DPDS and patients without DPDS.

Disconnected pancreatic duct syndrome in acute pancreatitis

The review is devoted to diagnosis and treatment of disconnected pancreatic duct syndrome (DPDS) in patients with acute pancreatitis. Data on terminology, indications and options for endoscopic transluminal interventions are presented in detail. The results of numerous studies evaluating clinical efficacy of various endoscopic and open surgical procedures are analyzed. Available data confirm advisability of staged treatment of DPDS with primary endoscopic drainage of pancreatic fluid accumulations in specialized centers.

Operative Pancreas Debridement in 2021: Who and When?

Introduction: Treatment of necrotizing pancreatitis (NP) has shifted in favor of a minimally invasive step-up approach rather than primary operative pancreatic debridement (OPD). We evaluated the contemporary role of OPD in NP treatment. Methods: Single institution retrospective review of 468 NP patients treated between 2011-2019. Operative pancreatic debridement included video-assisted retroperitoneal debridement (VARD), open and minimally invasive transgastric debridement, and open debridement with external drainage. NP patients whose treatment included OPD were compared with patients treated definitively without OPD. Results: Since 2011, 256/468 (55%) of patients were treated with OPD. Gender and comorbidity profile were similar between groups. Necrotizing pancreatitis etiology was more likely biliary (52% vs 32%) and less likely secondary to alcohol (19% vs 35%) in patients treated with OPD (p<0.001). Computed tomography severity index (CTSI) of pancreatic necrosis was similar between groups; however, infected necrosis was more common in patients who underwent OPD (68% versus 33%, p <0.001). Patients treated with OPD were more likely to have disconnected pancreatic duct syndrome (DPDS) (53% vs 29%, p <0.001). Among patients who underwent OPD during their treatment, 73% underwent OPD as their initial intervention at 73 ± 6 days after disease onset while 27% underwent OPD as salvage therapy at 95 ± 16 days after disease onset, p=0.1. Conclusions: Operative pancreatic debridement remains an important treatment modality in patients with pancreatic necrosis. OPD is employed as either primary or salvage therapy most frequently in patients with NP of biliary etiology, infected necrosis, and patients with disconnected pancreatic duct.

Cavitojejunostomy for post-traumatic disconnected pancreatic duct syndrome presenting as persistent external pancreatic fistula: A case report

Post-traumatic disconnected pancreatic duct syndrome (DPDS) can present as persistent external pancreatic fistula following percutaneous drainage (PCD) of pancreatic collection. Management of these cases can be difficult and involves a multidisciplinary approach. Here, we present a case of a 16-year-old boy who presented with persisted pancreatic fistula following initial management including PCD of peripancreatic collection following polytrauma 3 months prior. Magnetic resonance imaging showed a disconnected pancreatic duct. Intraoperatively, there was a disconnected and viable distal pancreas with a defect cavity measuring 2 × 2 cm at the neck of the pancreas. The wall of the cavity was anastomosed with a Roux limb of the jejunum (cavitojejunostomy). Post-operative recovery was uneventful and the patient remains asymptomatic at 2 months of follow-up. Cavitojejunostomy is a feasible and safe surgical option in DPDS with a well-formed cavity. This avoids dissection in difficult anatomical planes and preserves pancreatic parenchyma.

S3224 Management of Ruptured Walled Off Pancreatic Necrosis in Disconnected Pancreatic Duct Syndrome: A Case Series

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.

Indwelling double-pigtail plastic stents for treating disconnected pancreatic duct syndrome-associated peripancreatic fluid collections: long-term safety and efficacy.

Long-term transmural double-pigtail stent (DPS) placement is recommended for patients with disconnected pancreatic duct syndrome (DPDS) and peripancreatic fluid collections (peri-PFCs). The long-term safety and efficacy of indwelling DPSs were evaluated. Medical files of patients treated with DPS for DPDS-associated peri-PFC and with a follow-up ≥ 48 months were reviewed. Early ( < 30 days) and late complications of DPS placement were evaluated and the primary endpoint, i. e., incidence of late complications per 100 patient-years of follow-up, was calculated. Short- and long-term success rates of endoscopic treatment and rate of peri-PFC recurrence were among secondary endpoints. From 2002 to 2014 we identified 116 patients, with mean (SD) follow-up of 80.6 (34.4) months. Among early complications (n = 20), 6 occurred peri-interventionally. Late complications (n = 17) were mainly pain due to DPS-induced ulcer or erosion (n = 10) and 14 of these were treated conservatively or by stent removal; 2 gastro-pancreatico-colo-cutaneous fistulas and 1 persisting bleed required surgical intervention. No DPS-related deaths were recorded. The incidence rate (95 %CI) of late complications was 2.18 (1.27-3.49) per 100 patient-years of follow-up. Short- and long-term success rates (with 95 %CI) of endoscopic treatment were 97.4 % (94.5 %-100 %) and 94 % (89.6 %-98.3 %), respectively. The peri-PFC recurrence rate was 28 % (20.1 %-35.9 %), and 92.3 % of these occurred within the first 2 years. Stent migration, chronic pancreatitis, and length of stent (> 6 cm) were independently associated with higher rates of peri-PFC recurrence. Long-term transmural drainage with DPS is a safe and effective treatment for DPDS-associated peri-PFCs. However, about one quarter of peri-PFCs will recur.

Intentional internal drainage tube method for nonlocalized persistent pancreatic leakage: a case report

BackgroundPersistent pancreatic leakage (PL) due to disconnected pancreatic duct syndrome (DPDS) is associated with severe morbidity and mortality and it usually treated with internal drainage. However, in cases without localized fistula formation, internal drainage is challenging to perform. We report an original one-stage surgical approach for nonlocalized persistent PL, namely, the “intentional internal drainage tube method”.Case presentationA 49-year-old woman whose main pancreatic duct was penetrated during endoscopic retrograde cholangiopancreatography experienced severe PL. Peritoneal lavage and a second operation involving central pancreatectomy failed to relieve the symptoms, and nonlocalized PL persisted due to DPDS. Although we attempted a radical resection of the pancreatic remnants as a third strategy, the highly inflamed tissue and massive bleeding prevented the completion of the procedure. We sutured the pancreatic head margin and performed a pancreaticojejunostomy to the distal margin. Because these two cut margins could possibly be the source of the persistent PL, we created a hole at the Roux-en-Y jejunal limb, and a silicone drainage tube was inserted into the peritoneal space via this hole. Postoperatively, we continuously suctioned the intentional internal drainage tube, and the residual PL cavity gradually diminished. Even after removal of the tube, the residual PL drained internally into the jejunum through this hole.ConclusionsWe present this intentional internal drainage tube method as a novel alternative approach for the management of nonlocalized PL consequential of DPDS. Due to the simplicity and minimally invasive nature of this method, we propose this technique may also be used to treat various types of nonlocalized persistent PL or be used prophylactically for central pancreatectomy.

Spontaneous Fracture of Plastic Stents: A Rare Complication of Long-Term Indwelling Transmural Endoprosthesis

AbstractPermanent indwelling transmural stents is a safe and effective strategy for prevention of recurrence of pancreatic fluid collections following successful endoscopic transmural drainage of walled-off necrosis (WON) with coexistent disconnected pancreatic duct syndrome (DPDS). Long-term studies have shown this strategy to be safe and effective with rarely reported adverse effects. In this case series, we describe three patients of successfully treated WON and DPDS presenting later with a rare complication of permanent indwelling transmural plastic stents.

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

Introduction: Disconnected Pancreatic Duct Syndrome (DPDS), is the circumferential discontinuity of pancreatic duct such that the distal pancreas does not drain downstream into the duodenum as a result of severe acute or necrotising pancreatitis and can present either as pancreatic ascites or as external pancreatic fistula. Method: 37year old male, Post Necrotising Pancreatitis presented with Disconnected Pancreatic Duct Syndrome (DPDS) with left sided portal hypertension. He was initially managed with pig tail drainage which resulted in an controlled External Pancreatic Fistula. ERCP and Pancreatic stenting was done but failed in closure of the fistula. CECT abdomen showed features suggestive of displaced pancreatic duct stent. He underwent EXPLORATORY LAPAROTOMY WITH ROUX-EN-Y FISTULOJEJUNOSTOMY. Intraoperatively there was complete disruption of the pancreatic duct with an intrapancreatic collection of 2x2 cm, tip of the pig tail drain and pancreatic duct stent could be seen outside the parenchyma. Post operatively patient recovered satisfactorily. Result: ERCP with trans-papillary stenting or surgery remain the two pathways oftreatment but with high recurrence rates.When nonsurgical measures fail, surgical intervention may be warranted and roux en y internal drainage has been considered as optimal therapy. Surgical intervention may involve debridement, resection or drainage procedure. In patient with concomitant left sided portal hypertension drainage procedure may be a safer option. Conclusion: DDS needs multidisciplinary approaches to mend it and can be challenging and time consuming. Roux-en-Y Fistulojejunostomy is a good salvage procedure for Displaced Pancreatic Stent in Disconnected Pancreatic Duct Syndrome with Refractory External Pancreatic Fistula.