Pancreatic Ascites Research Articles

Prospective Outcomes of Standardized Non-operative Management of Pancreatic Trauma With Ductal Injury in Children: Less is More

BackgroundTraumatic pancreatic laceration with ductal injury in children can be managed non-operatively (NOM); however, variable management affects outcomes. We hypothesized that a standardized management approach with early feeding and limited resource utilization is safe and improves outcomes. MethodProspective, multicenter study of 13 pediatric trauma centers (2018–2022). Children with blunt pancreatic trauma with ductal injury were managed per a standard NOM pathway. Outcomes were compared to a historical NOM cohort with variable management. ResultsOf 22 patients, the median age was 7.5 years (range 1–14 years). Low-fat diet was started at median 4 days [IQR 2–7] and median hospital stay was 8 days [IQR 4–10]. One patient failed NOM and underwent distal pancreatectomy. Of the rest, most (17/21, 81%) had early recovery and discharged in median 6 days [IQR 4–8.25] while 4 (19%) had prolonged recovery (median stay 24 days, IQR 19.8–30.5) and higher peri-pancreatic cyst development (early 23.5% vs prolonged 75%,p = 0.05). Pancreatic ascites at presentation correlated with cyst development (p < 0.0001). Endoscopic stent (optional) was placed in 33% and did not prevent cyst development. Delayed exocrine pancreatic insufficiency was noted in 1 patient. Compared to the historic cohort (32 patients), TPN use was lower (pre-protocol 56% vs post 23%, p = 0.02), days to diet was shorter (pre-protocol 7 vs post 4; p = 0.03), and cyst development was lower (pre-protocol 81% vs post 33%, p < 0.001). ConclusionChildren with traumatic pancreatic ductal injury can be safely managed per the PTS NOM clinical pathway and most recover rapidly. Pancreatic ascites may predict pseudocyst formation. Levels of EvidenceIV. Study type: therapeutic, comparative.

S2396 Navigating Rare Complications: Pancreatic Ascites and Fungal Peritonitis in Acute-on-Chronic Pancreatitis

S2396 Navigating Rare Complications: Pancreatic Ascites and Fungal Peritonitis in Acute-on-Chronic Pancreatitis

CT Surveillance for Local Recurrence After Pancreatic Cancer Resection: Evaluation of Imaging Findings From the SAR Disease-Focused Panel Consensus Statement.

Background: A Society of Abdominal Radiology (SAR) Pancreatic Ductal Adenocarcinoma (PDAC) Disease-Focused Panel (DFP) consensus statement described findings suspicious for local recurrence (LR) on surveillance imaging after PDAC resection. Objective: To evaluate the interreader agreement and predictive utility of potential imaging findings of LR on serial surveillance CT examinations after Whipple procedure for PDAC, using the SAR PDAC DFP consensus statement. Methods: This retrospective study included 126 patients (mean age, 68.5±10.3 years; 72 men, 54 women) who underwent Whipple surgery for PDAC between January 2009 and December 2014. Three radiologists independently reviewed baseline and subsequent postoperative contrast-enhanced abdominopelvic CT examinations performed within 2 years postoperatively, evaluating features in the SAR PDAC DFP consensus statement relating to surgical bed stranding, surgical bed soft tissue, vessel encasement, main pancreatic duct dilatation, and ascites. Interreader agreement was calculated. The reference standard for LR development within 2 years postoperatively incorporated all available information. Imaging features' frequencies were calculated for recurrence examinations (i.e., first surveillance examinations indicating LR). For baseline postoperative examinations, features associations' with eventual LR development were assessed by multivariable logistic regression analysis. Results: LR developed within 2 years postoperatively in 81/126 patients. For both baseline and subsequent examinations, agreement for stranding and soft tissue morphology were poor, for vessel encasement was fair, for soft tissue and ascites were moderate, and for main pancreatic duct dilatation was substantial. On recurrence examinations, across readers, new or increased stranding was present in 27-77%; new or increased soft tissue, 80-86%; soft tissue with vessel encasement and luminal narrowing, 36-59%; new or increased main pancreatic duct dilatation, 25-26%; and new or increased ascites, 20-23%. On baseline postoperative examinations, independent predictors of eventual LR were soft tissue for all three readers (OR=2.78-6.85) and stranding for reader 1 (OR=3.59); main pancreatic duct dilatation and ascites were not independent predictors of LR for any reader. Conclusion: This study highlights the role of soft tissue, particularly when associated with vessel encasement and luminal narrowing, in raising suspicion for LR after PDAC resection. Clinical Impact: This study supports the SAR PDAC DFP consensus statement, while highlighting opportunities for continued optimization.

Pancreatic ascites, surgical resolution through laparoscopic cystogastrostomy

Pancreatic ascites, surgical resolution through laparoscopic cystogastrostomy

Early surgical Management of pancreatic ascites in chronic pancreatitis-Single centre experience

Early surgical Management of pancreatic ascites in chronic pancreatitis-Single centre experience

Prognosticators of survival in patients with metastatic pancreatic cancer and ascites

Identification of factors associated with survival after ascites diagnosis in metastatic pancreatic cancer (mPC) patients may guide treatment decisions and help to maintain quality of life in this highly symptomatic patient collective. All patients treated for mPC at the Medical University of Vienna between 2010 and 2019 developing ascites throughout their course of disease were identified by retrospective chart review. General risk factors, metastatic sites, systemic inflammation and liver function parameters, as well as type of treatment after ascites diagnosis were investigated for associations with survival. One hundred and seventeen mPC patients with ascites were included in this study. Median time from mPC to ascites diagnosis was 8.9 months (range 0-99 months) and median overall survival (OS) after ascites diagnosis was 27.4 days (range 21.3-42.6 days). Identified prognostic factors at ascites diagnosis independently associated with an impaired OS were presence of liver metastases [hazard ratio (HR): 2.07, 95% confidence interval (CI) 1.13-3.79, P= 0.018), peritoneal carcinomatosis (HR: 1.74, 95%CI 1.11-2.71, P= 0.015), and portal vein obstruction (HR: 2.52, 95%CI 1.29-4.90, P= 0.007). Compared with best supportive care, continuation of systemic therapy after ascites diagnosis was independently associated with survival (HR: 0.35, 95%CI 0.20-0.61, P < 0.001) with a median OS of 62 days (95%CI 51-129 days, P < 0.001) versus 16 days (95%CI 11-24 days), respectively. Liver and peritoneal metastases as well as portal vein obstruction were found to be prognostic factors after ascites diagnosis in mPC patients. Continuation of systemic therapy after ascites diagnosis was associated with a longer OS, which needs to be evaluated in larger clinical trials including quality-of-life assessment.

Extra-splanchnic vascular thrombosis in pancreatic ascites: a case series

Pancreatic ascites is a dreaded complication of acute or chronic pancreatitis. It’s a therapeutic challenge with its effect on nutrition and the associated complications. Pancreatic ascites can lead to formation of pseudo aneurysm by direct erosion of vessel, but extra splanchnic vascular complications are rare. In this series of 5 cases, we report an unusual incidence of extra splanchnic vascular complications in cases of pancreatic ascites. Out of the 21 cases of pancreatic ascites treated over a period of 2 years (February 2021 to February 2023) in our centre, we encountered 5 cases with vascular complications in the extra splanchnic circulatory system like pulmonary, cerebral, and cardiac. All these cases didn’t show a thrombus in IVC or leg veins in Doppler study. Among these 5 patients, three succumbed to the complications. This highlights the need of targeted evaluation for thrombosis in systemic circulation, especially pulmonary circulation for all patients of pancreatic ascites. Though a causal association cannot be proved by this report, the increased incidence of pulmonary thrombosis in pancreatic ascites patients need further evaluation and work up and detailed analysis. Targeted evaluation and urgent treatment in the form of anticoagulation along with surgical or endoscopic treatment of pancreatic leak may halt the ongoing pro coagulation cascade.

S2132 Hemorrhagic Pancreatic Ascites Treated With Pancreatic Duct Stenting

S2132 Hemorrhagic Pancreatic Ascites Treated With Pancreatic Duct Stenting

S3305 Endoscopic Management of Pancreatic Ascites Following Surgical Fenestration of a Large Symptomatic Hepatic Cyst

S3305 Endoscopic Management of Pancreatic Ascites Following Surgical Fenestration of a Large Symptomatic Hepatic Cyst

S2214 Pancreatic Ascites as a Result of Chronic Pancreatitis

S2214 Pancreatic Ascites as a Result of Chronic Pancreatitis

A possible manifestation of pancreas divisum–pancreatic pseudocyst in an infant with no apparent history of pancreatitis: a case report

BackgroundPancreas divisum (PD), the most common pancreatic anomaly, is caused by the failure of pancreatic bud fusion in the embryo. Although most cases are asymptomatic, it can cause pancreatitis or epigastric pain. We report an unusual case of PD in an infant.Case presentationThe patient was a 9-month-old girl with no pertinent medical history. She had suffered vomiting and diarrhea for 1 week before transfer to our hospital. Her general condition was poor, and abdominal distention was noted. Blood tests revealed microcytic anemia with normal chemical markers. The parents reported no episode of pancreatitis. Ultrasonography revealed massive ascites, which was later found to be bloody. Enhanced computed tomography and magnetic resonance imaging depicted a cystic lesion, approximately 2 cm in size, anterior to the second portion of the duodenum. During exploratory laparotomy, a pinhole was identified on the cyst wall, which was mistakenly identified as a duodenal perforation, and direct closure was performed. Postoperative levels of serum amylase and inflammation markers were elevated, and the amount of ascites increased, impairing oral feeding. The level of pancreatic enzymes in the ascites was high. Imaging studies were repeated, but the cause of pancreatic fistula was not identified. Conservative therapy, including administration of total parenteral nutrition, antibiotics, and octreotide, was initiated, but the situation did not improve. Three months after admission, endoscopic retrograde cholangiopancreatography showed a thick dorsal pancreatic duct communicating with a hypoplastic ventral duct, which was indicative of PD. Contrast medium leaking from the dorsal duct near the minor ampulla revealed the presence of a pseudocyst. Stenting via the minor papilla was impossible because the minor papilla was obstructed. Instead, a stent was inserted into the ventral pancreatic duct. Endoscopic transgastric drainage of the cyst was effective, and the patient was discharged, 7 months after admission. The patient is healthy, but the gastric stent needs to be replaced regularly.ConclusionIn children, PD can manifest with pancreatic pseudocyst that causes pancreatic ascites, even in the absence of pancreatitis. This may be a previously unrecognized manifestation of PD in children, and clinicians need to be aware of it.

Autoimmune Pancreatitis with Massive Ascites and Multiple Pancreatic Cysts Successfully Treated with Prednisolone: A Case Report.

A 64-year-old man with a history of diabetes and gallstones was admitted to our institution with suspected pancreatic malignancy. Computed tomography (CT) revealed multiple pancreatic cysts and massive ascites, and endoscopic ultrasonography (EUS) revealed a 28×27-mm hypoechoic mass in the pancreatic head. An EUS-guided fine-needle aspiration biopsy was performed, and there were no malignant findings. Based on the test results and imaging findings, type 1 autoimmune pancreatitis was suspected. The patient was administered 30 mg of prednisolone daily. After 11 days, CT revealed that the pancreatic cysts and ascites had reduced in size.

Abstract 2148: Robust detection of somatic genetic alterations in pancreatic cancer ascites

Abstract Introduction: Regardless of the stage at diagnosis most patients with pancreatic ductal adenocarcinoma develop peritoneal disease and some malignant ascites (MA) as well. Prior studies have shown that MA negatively affects overall treatment efficacy and survival. Despite the clinical significance of MA it has not been studied to any great extent. Methods: We collected MA and matched normal tissue samples at autopsy from 20 PDAC patients who were initially diagnosed at stages IIB to IV. Whole exome or targeted sequencing was previously performed on each PDAC. Each MA sample was centrifuged twice at 4000 RPM first and then at 15000 RPM to separate the cell pellet (CP) from the cell-free ascites fluid. We next extracted DNA from the CP, matched normal tissue, and the cell-free DNA (cfDNA) from the ascites fluid, and all were submitted to the Genomics Core for MSK-IMPACT, a targeted cancer gene panel representing 505 genes. Results: Results of the first five patients are complete and the remaining are in process. Comparison of the CPs and/or cfDNA to the matched tumor samples indicated 100% concordance for detected variants. However, the somatic alterations of the CP specifically versus the matched cfDNA were divergent in all patients analyzed thus far. Virtually all copy number alterations in all patients were deep deletions (range 66 to 187 cancer genes deleted) affecting multiple DNA repair pathways including homologous recombination deficiency and microsatellite repair. Conclusions: Samples of MA, when both the cell pellet and cfDNA are sequenced, accurately represent the genetic features of the matched PDAC tissue and may serve as an alternative mode of sampling for precision medicine. Differences in the genetics of the CP versus the cfDNA suggest polyclonality in the peritoneal space. Moreover, the finding of deep deletions in targetable DNA repair pathways suggest a therapeutic vulnerability for exploration. Given that paracentesis is often performed in the palliative setting and may be performed multiple times over the course of a patients’ management, it also offers an opportunity to determine how clonal dynamics in the peritoneal space change over time. Patients with MA have poor overall survival compared to patients without MA so these patients may benefit from this type of tracking which could potentially help with their treatment. Citation Format: Rajya L. Kappagantula, Alvin P. Makohon-Moore, Shigeaki Umeda, Elias-Ramzey R. Karnoub, Jerry P. Melchor, Laura D. Wood, Christine A. Iacobuzio-Donahue. Robust detection of somatic genetic alterations in pancreatic cancer ascites [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2148.

Dynamic Changes in Serum Cytokine Profile in Rats with Severe Acute Pancreatitis

Background and Objectives: Most published research has only investigated a single timepoint after the onset of severe acute pancreatitis (SAP), meaning that they have been unable to observe the relationship between the dynamic changes in cytokines and SAP progression. In this study, we attempted to reveal the relationship between dynamic changes in cytokine expression levels and SAP disease progression and the relationship between cytokines, using continuous large-scale cytokine detection. Materials and Methods: Seventy rats were randomly assigned to control (Con), sham operation (SO) and SAP groups. The SAP group was randomly allocated to five subgroups at 3, 6, 9, 12 and 15 h after the operation. In the SAP group, 5% sodium taurocholate was injected retrograde into the pancreatic bile duct. Animals in the SO group received a similar incision, a turning over of the pancreas. Control animals did not receive any treatment. We observed the survival, ascites fluid amount, pancreatic histopathological scores and serum amylase activity of SAP rats. We used the cytokine microarray to simultaneously detect 90 cytokines and the dynamic changes in one experiment and to analyze the correlation between cytokine expression and disease progression. Results: The mortality of SAP rats increased with an increase in time. Serum amylase activity, pancreatic histopathological scores and ascites fluid amount were time-dependent. Compared with normal rats, 69 cytokines in SAP rats were significantly changed for at least one timepoint, and 49 cytokines were significantly changed at different timepoints after SAP induction. The changes in inflammatory cytokines were significantly upregulated at 6 and 9 h and 12 h and then significantly decreased. Conclusions: The trend of cytokine expression in SAP rats was not consistent with the disease progression. The cytokine-cytokine receptor interaction and MAPK signal's dominant cytokines were always highly expressed at various time points over the course of SAP.

Successful Treatment of Pancreatic Pseudocysto-Duodenum Fistula with Ultrasound Endoscopic Drainage: A Case Report

Pancreatic pseudocysts represent a complication of acute interstitial edematous pancreatitis with a frequency of about 10–20%, and most of these resolve spontaneously. Treatment is indicated only in patients who develop symptoms such as abdominal pain, gastric outlet obstruction, jaundice for compression of the biliary system, or in case of infection. Pancreatic pseudocysts’ complications include pseudocyst infection leading to sepsis, rupture with pancreatic ascites, bleeding or formation of pseudoaneurysm, and, rarely, fistulization to other viscera. The most common sites for fistulas are between cysts and the stomach, duodenum, and colon. Here, we present the case of a patient with severe acute pancreatitis who developed multiple infected fluid collections with a cysto-duodenum fistula that was successfully treated with endoscopic intervention.

Chronic pancreatitis: about some complications and features of their pathogenesis and course

The review article provides up-to-date information on the complications of pancreatitis that are important for the tactics and strategy of patient management both at the inpatient and outpatient stages of observation. The purpose of the review was to emphasize the importance of complications for the course and life of patients with chronic pancreatitis. The authors draw the attention of internists to the course of such complications as pseudocysts, cysts, fistulas, thrombohemorrhagic, cholestatic syndromes, compression syndrome of adjacent organs, pancreatic encephalopathy (acute and chronic). The symptomatology of complications of chronic pancreatitis is discussed in detail, which is very important for differential diagnosis with the corresponding diseases. Such complications include the formation of erosive and ulcerative lesions, varicose veins of the esophagus and bleeding from varicose veins of the esophagus and stomach, portal hypertension syndrome with pancreatic ascites and chronic pancreatic encephalopathy, idiopathic non-cirrhotic portal hypertension, pancreatic cancer. The authors emphasize the need to analyze the corresponding symptoms, indicating the possibility of complications, negative consequences with each recurrence or exacerbation of chronic pancreatitis, since it concerns the prognosis and life of the patient.

S1828 Recurrent Pancreatitis Secondary to Adderall Use With Pancreatic Ascites: A Sight Typically Unseen

Introduction: Pancreatic ascites is a rare disease with a prevalence of 3.5% resulting from pancreatic duct injury. While small ascites resolves spontaneously, large volume, persistent ascites can cause significant morbidity and mortality. We present a case of pancreatic ascites in a patient with recurrent pancreatitis from Adderall use. Case Description/Methods: 38-year-old female with attention deficit hyperactive disorder (ADHD), remote alcohol use, and recurrent pancreatitis complicated by pseudocyst and ascites presented with acute on chronic epigastric pain. Her last reported alcohol use was 2 years ago. Home medications included Adderall (amphetamine and dextroamphetamine) and benzodiazepines. Physical examination revealed normal vital signs, severe cachexia and peripheral edema. Abdomen was distended with epigastric tenderness. Pertinent labs included hemoglobin of 10.8g/dl, calcium 7.6mg/dl, albumin 1.7g/dl and a lipase of 462U/l. Bilirubin, transaminases, alkaline phosphatase and INR were normal. Quantitative immunoglobulins, IgG4, triglycerides and thyroid stimulating hormone were within normal limits. Blood alcohol and phosphatidylethanol (PETH) levels were negative. Previous CT scan demonstrated pancreatic head cyst (4.6cm), stable pseudocysts in the head and body, peripancreatic inflammation and large abdominal ascites. MRCP this admission revealed pancreatic head fluid collection decreased in size (2.3cm), consistent with walled off necrosis (Figure). Diagnostic paracentesis was significant for: WBC 93 cells/mm3, PMN 25%, RBC 2050 cells/mm3, protein 1.9g/dl, lactate dehydrogenase 102U/L, amylase 1496U/L and a serum ascites-albumin gradient (SAAG) < 1.1. An endoscopic retrograde cholangiopancreatography (ERCP) was pursued due to suspicion for pancreatic ascites which showed abrupt cut off of the pancreatic duct in the head, without filling of the pancreatic duct in the body or tail likely due to stricture. A pancreatic stent was placed into the ventral pancreatic duct to maintain patency with plan for endoscopic ultrasound examination (EUS) to exclude obstructive pathology. Discussion: Pancreatic ascites is often seen with recurrent pancreatitis commonly of alcoholic etiology. Our patient had recurrent pancreatitis and ascites due to chronic adderall use. While pancreatitis from adderall use is rare, presentation with ascites can pose a diagnostic challenge. Hence, clinicians should familiarize themselves with early diagnosis and endoscopic management which improves prognosis in this rare disease.Figure 1.: MRCP images revealing large volume ascites (red arrow), walled off necrosis in the pancreatic head (yellow arrow) and peripancreatic inflammation (blue arrow).

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.

S358 Endoscopic Ultrasound-Directed Transgastric ERCP for Pancreatic Duct Stent Placement to Treat Pancreatic Ascites

Introduction: Endoscopic ultrasound (EUS)-Directed transGastric ERCP (EDGE) is an advanced procedure utilized to enable pancreaticobiliary access in patients with Roux-en-Y gastric bypass anatomy. We hereby present a case of refractory pancreatic ascites from a persistent pancreatic duct (PD) leak treated with EDGE and transpapillary PD stenting. Case Description/Methods: A 62-year-old White female with history of morbid obesity with Roux-en-Y gastric bypass and biliary pancreatitis with prior cholecystectomy was referred for refractory pancreatic ascites causing significant abdominal pain, poor oral intake and weight loss necessitating total parenteral nutrition. MRCP showed a PD leak in the body as cause for ascites (Fig. 1). After multidisciplinary team discussion, a staged EDGE for PD stenting was pursued. The gastric remnant was identified endosonographically through the jejunum, a 19G needle was advanced into it and 500 ml of saline was instilled to dilate the remnant. A 0.025 guidewire was coiled in the remnant and a 15mm by 10 mm cautery enhanced lumen apposing metal stent (LAMS) delivery system was used to create a jejunogastrostomy followed by LAMS deployment. LAMS was post dilated to 15 mm and ERCP was pursued after 10 days. During ERCP, PD leak at the body was confirmed on the pancreaticogram. A 5 Fr by 15 cm single pigtailed stent was deployed to bridge this leak. A large biliary sphincterotomy was also performed for a subjectively stenotic major papilla. Follow up CT scan after 1 month showed resolution of pancreatic ascites and repeat ERCP confirmed resolution of the PD leak. The biliary and pancreatic stents were removed. The jejunogastrostomy stent was removed after three months. She continues to remain asymptomatic and is tolerating a regular diet. Discussion: This case demonstrates the successful use of EDGE procedure for management of refractory pancreatic ascites from a pancreatic duct leak. EDGE for pancreatic endotherapy in Roux-en-Y gastric bypass anatomy is a safe and effective alternative to more invasive laparoscopy or percutaneous gastrostomy access to the gastric remnant and should be considered in cases with ascites. Watch the video at https://tinyurl.com/ACGAbstractS358Figure 1.: MRCP With Pancreatic Duct Leak.

S1922 A Twisted Plot: Pancreas Divisum With Right-Sided Pancreaticopleural Fistula

Introduction: We report on a 53-year-old male with a past medical history significant for chronic pancreatitis who presented with a right-sided pleural effusion secondary to pancreaticopleural fistula with pancreatic divisum. Pleural effusion secondary to pancreaticopleural fistula (PPF) is a rare complication of acute or chronic pancreatitis and usually presents with a left-sided pleural effusion. This case also highlights the difficulty and significant delay in diagnosing pancreas divisum on cross-sectional imaging. Case Description/Methods: A 53-year-old male with a medical history significant for chronic pancreatitis complicated by pancreatic ascites, walled-off necrosis, splenic and portal vein thrombosis, alcoholic gastritis, and polysubstance use presented with five days of dyspnea with new and worsening oxygen requirements. Chest x-ray showed a new moderate right-sided pleural effusion. Pleural fluid analysis revealed elevated lipase of >3,000 U/L and amylase of 21,008 U/L concerning for a pancreaticopleural fistula. MRI of pancreas showed a disconnected duct at the tail of the pancreas with a fistula extending into the mediastinum and peritoneum. During ERCP a bulging minor papilla was noted. After failed initial attempts at cannulating ventral duct, minor papilla was approached and dorsal duct was cannulated. Pancreatogram revealed a complete pancreatic divisum with a leak in the tail of the pancreas. A temporary plastic stent was placed in the dorsal duct after minor papilla sphincterotomy. The patient's symptoms resolved and he was discharged home with outpatient follow-up (Figure). Discussion: PPF is a rare complication of pancreatitis that typically presents as large, recurrent, left-sided pleural effusion often refractory to thoracentesis management. Transpapillary stent placement in the pancreatic duct is widely used in the management of PPF. Our case shows a rare right-sided presentation of PPF in the setting of a newly diagnosed pancreas divisum missed on numerous previous cross-sectional imaging. High clinical suspicion of underlying divisum raised by endoscopic and imaging findings led to successful endoscopic management of this complex case.Figure 1.: MRCP Pancreas showing pancreas divisum and disconnected duct.