Disconnected Pancreatic Duct Syndrome Research Articles

Permanent Indwelling Transmural Stents for Endoscopic Treatment of Patients With Disconnected Pancreatic Duct Syndrome: Long-term Results.

Disconnected pancreatic duct syndrome (DPDS) is defined as the complete disruption of the main pancreatic duct, the result are peripancreatic fluid collections or pancreatic leaks. The aim of this study was to report the results of derivative endoscopic treatment of DPDS in a long-term follow-up period. We performed a retrospective analysis of prospectively collected data. Endoscopic treatment consisted of transmural drainage with 2 double pigtail plastic stents (7 F and 4 cm) deployed under endoscopic ultrasound guidance. In total, 21 patients were included in our study. There were 15 (71%) men and the median age was 36 years (range, 23 to 86 y). The principal etiology of DPDS was acute pancreatitis. A total of 20 (95.2%) patients were diagnosed with DPDS by endoscopic pancreatography and only 1 (4.8%) patient by magnetic resonance cholangiopancreatography (MRCP). The median follow-up time was 28 months (range, 7 to 76 mo). Technique success was 100% and initial clinical success was 80.9% (17/21). Three (17.6%) of these patients required a new endoscopic procedure with success in all cases. During follow-up, 11 (52%) patients developed diabetes mellitus and 3 patients (14%) developed exocrine pancreatic insufficiency. There were 5 (15%) patients with complications. According to our data, endoscopic treatment with the placement of a permanent indwelling transmural stents is a useful and safe tool for the treatment of DPDS.

Su1317 EUS Correlates of Disconnected Pancreatic Duct Syndrome (DPDS)

Su1317 EUS Correlates of Disconnected Pancreatic Duct Syndrome (DPDS)

Impact of Nasojejunal Feeding on Outcome of Patients with Walled Off Pancreatic Necrosis (WOPN) Presenting with Pain: a Pilot Study

BackgroundDrainage is usually recommended in symptomatic walled off pancreatic necrosis (WOPN). WOPN presenting with pain may get symptomatic relief if the pancreas is given rest by initiating nasojejunal (NJ) feed. AimThe aim of this was to prospectively study the efficacy of nasojejunal (NJ) feeding in patients of WOPN presenting with abdominal pain. MethodsTwenty-one patients (15 M; 35 ± 12 years) with WOPN (size 7–16 cm) presenting with pain underwent NJ tube placement under endoscopic guidance. Following this, pain relief and long-term outcome were studied. ResultsEtiology of pancreatitis was alcohol in 12, gall stones in 6, and idiopathic in 3 patients. NJ tube was successfully placed in all patients and 17/21 (81 %) patients had symptomatic relief in 1–4 days (mean 2 ± 1 days) following NJ feeding. NJ tube was removed after 7–10 days (mean 7 ± 1 days), and 14 (61 %) patients remained pain free and follow-up imaging (1–8 months) revealed complete resolution or decrease in size of WOPN. Three patients had recurrence of pain and were successfully treated with endoscopic drainage. ConclusionsNJ feeding improves pain in the majority of patients with WOPN and thus obviates or delays drainage. Majority of nonresponders had disconnected pancreatic duct syndrome (DPDS).

Mo1419 Prevention of Recurrence of Fluid Collections in Walled Off Pancreatic Necrosis and Disconnected Pancreatic Duct Syndrome: Comparative Study of One Versus Two Long Term Transmural Stents

Disconnected pancreatic duct syndrome (DPDS) can occur in up to 50% of patients with walled off pancreatic necrosis (WOPN). To prevent recurrences of pancreatic fluid collections (PFC's) in these patients, placement of long term indwelling transmural stents has been shown to be an effective and safe strategy. As stents get blocked over a period of time, it has been suggested that instead of a single stent, placement of multiple stents would be a better strategy as the pancreatic secretions can continue to drain in between the stents.

Mo1362 Multidisciplinary Approach to Disconnected Pancreatic Duct Syndrome (DPDS) in Acute Pancreatitis (AP) - A Single Tertiary Center Experience

Mo1362 Multidisciplinary Approach to Disconnected Pancreatic Duct Syndrome (DPDS) in Acute Pancreatitis (AP) - A Single Tertiary Center Experience

Factors determining recurrence of fluid collections following migration of intended long term transmural stents in patients with walled off pancreatic necrosis and 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: disease classification and management strategies.

Disconnected pancreatic duct syndrome (DPDS) typically complicates acute necrotizing pancreatitis (ANP) and presents as a pseudocyst months after the initial episode of pancreatitis. However, our experience suggests that the presentation of DPDS may be quite varied and might require significant evaluation and judgment before surgical intervention. We sought to determine the presentations of DPDS and assess the management of the various forms of presentation. A retrospective review of all patients with DPDS between July 2005 and June 2011 was performed. Patients were included when CT scan demonstrated a clear disconnected pancreas that was confirmed at operation. Medical records were reviewed in detail to determine clinical presentation, management, and outcomes. Of the 50 patients identified, 66% were male, with a mean age of 53 ± 16 years. Mortality was 2% and 3 patients (6%) required late reoperation. The DPDS presented in 3 forms: diagnosed concurrently with ANP (concurrent DPDS; n = 28); delayed presentation with a pseudocyst (delayed DPDS; n = 15); and as a consequence of chronic pancreatitis (CP) (CP DPDS; n = 7). Concurrent DPDS was treated with necrosectomy including body/tail resection within 60 days of onset and complicated by a grade B/C fistula in 36%. Delayed DPDS required distal pancreatectomy 440 days after diagnosis, with a 7% fistula rate. Chronic pancreatitis DPDS was treated with lateral pancreatojejunostomy at 417 days with no fistulas. Disconnected pancreatic duct syndrome presents concurrently with ANP, in a delayed fashion, or infrequently in the setting of CP. Prompt recognition and classification with appropriate operative therapy results in low mortality and nonoperatively managed pancreatic fistulas.

Su1711 Management of Pancreatic Ductal Leaks in Patients With Chronic Pancreatitis

Su1711 Management of Pancreatic Ductal Leaks in Patients With Chronic Pancreatitis

Disconnected Pancreatic Duct Syndrome

Disconnected pancreatic duct syndrome (DPDS) is characterised by disruption of the main pancreatic duct with a loss of continuity between the pancreatic duct and the gastrointestinal tract caused by ductal necrosis after severe acute necrotising pancreatitis treated medically, by percutaneous drainage, or necrosectomy.There are no clear epidemiological data on the real incidence of DPDS; approximately 10%–30% of patients with severe acute pancreatitis could develop DPDS. The existing literature is scarce, the terminology is confusing and therapeutic algorithms are not clearly defined. Both endoscopic management and surgical management have been described.We have performed a systematic review of the literature on DPDS.

Endoscopic treatment for complex biliary and pancreatic duct injuries

AbstractSevere injuries of biliary or pancreatic ducts are associated with significant morbidity and mortality. Severe bile duct injuries such as major biliary leaks, complete transection, or complete occlusion of bile ducts can be grouped under the term complex bile duct injuries (CBDI). In the spectrum of pancreatic duct injuries, disconnected pancreatic duct syndrome (DPDS) represents the most severe form and most often occurs after a severe episode of acute pancreatitis. Treatment of these complex injuries is quite challenging and for many years surgical management has been considered the treatment of choice. However, in the past few years, some studies have reported the successful management of CBDI or DPDS using endoscopic procedures alone or in combination with a percutaneous approach. In this review, we detail the endoscopic or combined endoscopic/percutaneous treatment possibilities for CBDI and DPDS.

Factors impacting treatment outcomes in the endoscopic management of walled‐off pancreatic necrosis

Treatment outcomes are suboptimal for patients undergoing endoscopic treatment of walled-off pancreatic necrosis (WOPN). The objective of this study is to identify factors that impact treatment outcomes in this patient subset. This is a retrospective study of patients with WOPN treated endoscopically over 10 years. Patients underwent placement of stents and nasocystic catheters within the necrotic cavity. In select patients, the multiple transluminal gateway technique (MTGT) was adopted to create several openings in the stomach or duodenum to facilitate drainage of necrosis. In patients with disconnected pancreatic duct syndrome (DPDS), the transmural stents were left in place indefinitely to decrease pancreatic fluid collection (PFC) recurrence. Endoscopic treatment was successful in 53 of 76 (69.7%) patients. Treatment success was higher in patients undergoing MTGT than in those in whom conventional drainage was used (94.4% vs. 62.1%, P = 0.009). On multivariate logistic regression analysis, only MTGT (OR 15.8, 95% CI 1.77-140.8; P = 0.01) and fewer endoscopic sessions being needed (OR 4.0, 95% CI 1.16-14.0; P = 0.03) predicted treatment success. PFC recurrence was significantly lower in patients with indwelling transmural stents than in patients in whom the stents were removed (0 vs. 20.8%; P = 0.02). Creating multiple gateways for drainage of necrotic debris improves treatment success, and not removing the transmural stents decreases PFC recurrence in patients undergoing endoscopic drainage of WOPN.

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

IntroductionThere is limited data on the long term consequences and safety profile of long term indwelling transmural stents after successful treatment of walled off pancreatic necrosis (WOPN). AimTo retrospectively evaluate consequences of long term indwelling transmural stents in patients with WOPN. MethodsThe records of patients who underwent endoscopic transmural drainage of WOPN and had disconnected pancreatic duct syndrome (DPDS) were analyzed. ResultsThirty patients (26 M; mean age 37.1 ± 7.8 years) with long term indwelling transmural stents and DPDS were followed up for a mean of 20.4 ± 12.2 months (range: 3–38 months). The etiology of acute necrotizing pancreatitis was alcohol in 21, gall stones in 7 and idiopathic in 2 patients. In all patients two or three, 7 (17 patients) or 10 Fr (13 patients) 5 cm double pigtail stents were placed. ERCP revealed disconnected PD at the pancreatic head, body and tail region in 22, 7, and 1 patient respectively. Five patients (16.6%) had spontaneous migration of stents (both the stents in four patients and one stent in one patient; 7 Fr in four and 10 Fr in one patient respectively). Stent migration led to recurrence of pancreatic fluid collection (PFC) in one patient whereas in the remaining 4 patients it did not cause any symptoms. There was no recurrence of symptomatic PFC in remaining 25 patients. ConclusionLong term indwelling transmural stents in patients with WOPN and DPDS seem to be safe and also appear to decrease the risk of PFC recurrence.

Síndrome del ducto pancreático desconectado

Disconnected pancreatic duct syndrome (DPDS) is characterized by disruption of the main pancreatic duct with a loss of continuity between the pancreatic duct and the gastrointestinal tract caused by ductal necrosis after severe acute necrotizing pancreatitis treated medically, by percutaneous drainage, or necrosectomy.There are no clear epidemiological data on the real incidence of DPDS; approximately 10 to 30% of patients with severe acute pancreatitis could develop DPDS. The existing literature is scarce, the terminology is confusing and therapeutic algorithms are not clearly defined. Both endoscopic and surgical management have been described.We have performed a sytematic review of the literature on DPDS.

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

An external pancreatic fistula (EPF) generally results from an iatrogenic manipulation of a pancreatic fluid collection (PFC), such as walled-off pancreatic necrosis (WOPN). Severe necrotizing pancreatitis can lead to complete duct disruption, causing disconnected pancreatic duct syndrome (DPDS) with viable upstream pancreas draining out of a low-pressure fistula created surgically or by a percutaneous catheter. The EPF can persist for months to years, and distal pancreatectomy, often the only permanent solution, carries a high morbidity and defined mortality. To describe 3 endoscopic and percutaneous rendezvous techniques to completely resolve EPFs in the setting of DPDS. A retrospective review of a prospective database of 15 patients who underwent rendezvous internalization of EPFs. Tertiary-care pancreatic referral center. Fifteen patients between October 2002 and October 2011 with EPFs in the setting of DPDS and resolved WOPN. Three rendezvous techniques that combined endoscopic and percutaneous procedures to internalize EPFs by transgastric, transduodenal, or transpapillary methods. EPF resolution and morbidity. Fifteen patients (12 men) with a median age of 51 years (range 24-65 years) with EPFs and DPDS (cutoff/blowout of pancreatic duct, with inability to demonstrate upstream body/tail of pancreas on pancreatogram) resulting from severe necrotizing pancreatitis underwent 1 of 3 rendezvous procedures to eliminate the EPFs. All patients were either poor surgical candidates or refused surgery. At the time of the rendezvous procedure, WOPN had fully resolved, DPDS was confirmed on pancreatography, and the EPF had persisted for a median of 5 months (range 1-48 months), producing a median output of 200 mL/day (range 50-700 mL/day). The rendezvous technique in 10 patients used the existing percutaneous drainage fistula to puncture into the stomach/duodenum to deliver wires that were captured endoscopically. The transenteric fistula was dilated and two endoprostheses placed into the lesser sac. A second technique was used in 3 patients where EUS was used to avoid large varices and create a fistula to the percutaneous drainage catheter. Wires were delivered transenterally then grasped by an interventional radiologist. The new fistula was dilated, and, again, two endoprostheses were placed. Two patients underwent a rendezvous technique that resulted in transpapillary stents and removal of percutaneous catheters. The median duration to EPF closure was 7 days (range 1-73 days) during a median follow-up of 25 months (range 6-113 months). No EPF has recurred in any patient, although 3 symptomatic fluid collections have occurred. These collections have been successfully treated with combined percutaneous and endoscopic treatment or endoscopic treatment alone. One patient had postprocedural fever. There were no associated deaths. Small, selected group of patients without a comparative group. The management of EPFs in the setting of DPDS is challenging but can be treated effectively by combined endoscopic and percutaneous rendezvous techniques. The rendezvous procedures were associated with minimal morbidity, no mortality, avoidance of surgery, and complete elimination of the EPFs.

Roux-en-Y drainage of a pancreatic fistula for disconnected pancreatic duct syndrome after acute necrotizing pancreatitis

BackgroundAfter acute necrotizing pancreatitis (ANP), a pancreatic fistula may occur from disconnected pancreatic duct syndrome (DPDS) where a segment of the pancreas is no longer in continuity with the main pancreatic duct. AimTo study the outcome of patients treated using Roux-Y pancreatic fistula tract-jejunostomy for DPDS after ANP. MethodsBetween 2002 and 2011, patients treated for DPDS in the setting of endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopanreatography (MRCP) documented main pancreatic duct disruption with Roux-Y pancreatic fistula tract-jejunostomy. ResultsIn all, seven patients with DPDS were treated. The median age was 62 years (range 49–78) and five were men. The cause of ANP was gallstones (2), alcohol (1), ERCP (1) and idiopathic (3). Pancreatic necrosectomy was done in six patients. Time from onset of pancreatitis to fistula drainage was 270 days (164–365). Pancreatic fistulae arose from DPDS in the head/neck (4) and body/tail (3). Patients had a median fistula output of 140ml (100–200) per day before surgery. The median operative time was 142min (75–367) and estimated blood loss was 150ml (25 to 500). Patients began an oral diet on post-operative day 4 (3–6) and were hospitalized for a median of 7 days (5–12). The median follow-up was 264 days (29–740). Subsequently, one patient required a distal pancreatectomy. After surgery, three patients required oral hypoglycaemics. No patient developed pancreatic exocrine insufficiency. ConclusionInternal surgical drainage using Roux-en-Y pancreatic fistula tract-jejunostomy is a safe and definitive treatment for patients with DPDS.

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

Information regarding the natural history, clinical characteristics, and outcomes of disconnected pancreatic duct syndrome (DPDS) is limited. To describe clinical characteristics and outcomes of DPDS. A retrospective review of the Mayo Clinic endoscopy and hospital service database. Tertiary-referral center. We identified 31 DPDS cases from 1999 to 2006. Endoscopic drainage of pancreatic-fluid collections. The relationship between demographic and clinical data with endoscopic treatment and clinical outcomes in DPDS cases. The median patient age was 53 years (range 20-83 years); 48% were men. The most common etiology of acute pancreatitis (AP) was biliary (55%) followed by idiopathic (27%). The median interval between the diagnoses of AP and DPDS was 56 days (range 3-251 days); the median follow-up after the last ERCP or surgical procedure was 7 months (range 0-90 months). The DPDS location included the following: pancreas head 6%, neck 58%, body 26%, and tail 10%. Twenty-six patients had initial endoscopic treatment (19 had long-term improvement; 7 failed treatment and required surgery) and 5 underwent immediate surgery. Mortality was 0%; 26% developed chronic pancreatitis (CP) and 16% diabetes mellitus (DM); 10% resolved completely, 45% had smaller fluid collections, and 26% patients were lost to follow-up. No relationship between demographic and clinical data with endoscopic and clinical outcomes was found. Endoscopic treatment temporarily improved DPDS, with a failure rate of 23%. Immediate surgery was not required in all cases. CP and/or pancreatic atrophy occurred relatively shortly after the DPDS diagnosis in 26% and DM in 16% of cases. DPDS did not lead to mortality. Early surgery may be considered after initially stabilizing the fluid collection with endoscopic therapy.

Disconnected pancreatic duct syndrome: imaging findings and therapeutic implications in 26 surgically corrected patients.

The lack of ductal continuity between a viable pancreatic tissue and the gastrointestinal tract results in the disconnected pancreatic duct syndrome (DPDS). The purpose of our study is to describe accurately the imaging features of CT scanning and endoscopic retrograde pancreatography (ERCP) that define the DPDS. We conducted a retrospective analysis of the computed tomography (CT) and ERCP examinations in 26 consecutive patients with surgically proven disconnected pancreatic ducts treated over a 5-year period at our institution. Two abdominal radiologists concurrently defined the imaging features (presence and size of fluid collection along the course of the pancreatic duct, upstream enhancing pancreatic parenchyma, and ERCP abnormalities) via consensus for both exams. Patient demographics, etiology of pancreatitis, surgical treatment, initial CT interpretation, and the delay between symptom onset to correct diagnosis were recorded. A discrete, intrapancreatic fluid collection (average size = 27 cm2 (range, 4-74 cm2) along the course of the main pancreatic duct with upstream viable pancreatic parenchyma was identified by CT in 26 cases. ERCP showed ductal obstruction at the level of the intrapancreatic fluid collection in all patients with extravasation of contrast in 14 (54%). All patients were treated by operation: 15 (58%) by internal drainage into a Roux-en-Y limb of jejunum and 11 (42%) by distal pancreatic resection. No prior CT interpretation correctly identified DPDS. The average delay between symptom onset and definitive diagnosis was 9.3 months (range, 3-36 months). A discrete intrapancreatic fluid collection along the expected course of the main pancreatic duct with viable upstream pancreatic parenchyma suggests the diagnosis of DPDS. ERCP findings of ductal obstruction at the level of this fluid collection with or without contrast extravasation confirm this diagnosis. Treatment is surgical and requires either internal drainage or distal pancreatic resection for complete resolution.