Pancreatic Duct Syndrome Research Articles

French reconnection: A conservative pancreato-enteric reconnection for disconnected pancreatic duct syndrome

Background/objectivesDisconnectedpancreatic duct syndrome (DPDS), a severe complication of acute necrotizing pancreatitis (ANP), may require surgery, usually by distal splenopancreatectomy, thus increasing the risk of diabetes. We describe a new technique reconnecting the distal pancreas to the digestive tract. MethodsThis technique was proposed after failure of non-surgical treatment and at least 3 months after the onset of ANP in non-diabetic or non-insulin dependent diabetic patients with a distal pancreas of at least 5 cm. The ruptured zone was identified and the distal side was anastomosed to the stomach or the jejunum. ResultsFrom 2013 to June 2019, 36 patients (median age = 49 years) with DPDS underwent a “French reconnection” procedure, indicated for chronic pain/recurrent pancreatitis (n = 35; 97%), persistent pancreatic fistula (n = 33; 91%), or digestive compression/fistulisation (n = 9; 25%). Median preoperative weight loss was 10 kg (4-27), the median number of hospitalisations per patient was 5(1–8) and 24(67%) patients had received endoscopic/percutaneous treatment. Surgery was performed in median 279(90–2000) days after ANP, laparoscopically in 9(25%) patients. The remnant pancreas (median length = 70 mm; range = 50–130) was anastomosed to the stomach (n = 30) or the jejunum (n = 6). There were 13(36%) postoperative grade B/C pancreatic fistulas and 3(10%) bleedings including one death (mortality = 3%). The median hospital stay was 18 (7–121) days. After a median follow-up of 24 (4–53) months, all pancreatic fistulas had healed and the clinical success rate was 91%. Median BMI increased from 22 to 25 kg/m2. In patients with normal pancreatic function, postoperative de novo endocrine and severe exocrine insufficiencies were observed in 4/27 (15%) and 7/22 (32%), respectively. ConclusionsThe “French reconnection” procedure, as an alternative to distal splenopancreatectomy for the treatment of DPDS, provides good control of symptoms and decreases the risk of pancreatic insufficiency.

Intentional endoscopic nasopancreatic drainage to a pancreatic fistula in the treatment of disconnected pancreatic duct syndrome.

Intentional endoscopic nasopancreatic drainage to a pancreatic fistula in the treatment of disconnected pancreatic duct syndrome.

S1507 Disconnected Pancreatic Duct Syndrome: To Drain or Not to Drain?

INTRODUCTION: Disconnected pancreatic duct syndrome (DPDS) is an uncommon complication of pancreatitis resulting in cellular necrosis and destruction of viable pancreatic tissue surrounding the duct, typically within the head or body of the pancreas. CASE DESCRIPTION/METHODS: 63-year-old male with a past history remarkable for recurrent acute necrotizing pancreatitis of unknown etiology presented with acute onset and progressively worsening abdominal pain. The patient had significant 15-year alcohol consumption history, but last ingestion was 2 years prior. He was recently discharge from a 10-day hospitalization for a previous “flare” in his pancreas that was managed conservatively. Abdominal exam is remarkable for mild to moderate tenderness throughout with moderate to severe tenderness in the epigastric and bilateral upper quadrants. Laboratory workup revealed an elevated lipase (115IU/L). CT abdomen/pelvis showed evolution of severe necrotizing pancreatitis, a large 15 cm necrotic collection replacing the pancreas neck and body, and residual enhancing pancreatic parenchymal tissue of the tail suggestive of DPDS. However, there was no fluid surrounding the disconnected pancreatic tail segment to be drained. Conservative management was recommended of the sterile necrosis as the patient was without signs of sepsis. DISCUSSION: DPDS, as the name suggests, occurs when the pancreatic duct becomes interrupted and typically occurs secondary to pancreatitis, whether that is from an acute necrotizing type, chronic relapsing type, or pancreatic fistula formation. The prevalence of this condition is unknown but estimated to occur in up to 23% of acute necrotizing pancreatitis cases. In our patient, findings of a necrotic collection replacing the pancreas neck and body with residual enhancing of the pancreatic tail was most easily seen on contrast-enhanced CT scan; however, ERCP or MRCP are other possible imaging modalities. Presence of DPDS makes the management of pancreatitis more complex and recurrence rates of DPDS can be as high as 30%. If the pancreatic duct is disrupted and there is accumulating fluid surrounding the disconnected segment of pancreas, the success rate of conservative management is usually minimal. Early pancreatic debridement or drainage is rarely helpful and is complicated by intra-abdominal hypervascularity and altered anatomy. Urgent drainage is indicated if the patient has worsening symptoms or septic signs attributable to infection of the fluid collection.Figure 1.: Contrast-enhanced computed tomography of the abdomen and pelvis demonstrating evolution of severe necrotizing pancreatitis with development of a large dominant 15 cm necrotic collection (yellow arrow) essentially replacing the pancreas neck and body. Residual enhancing pancreatic parenchymal tissue in the tail (red arrow) is highly suggestive of disconnected pancreatic duct syndrome.

Impact of disconnected pancreatic duct syndrome on endoscopic ultrasound-guided drainage of pancreatic fluid collections.

Endoscopic intervention for pancreatic fluid collections (PFCs) with disconnected pancreatic duct syndrome (DPDS) has been associated with failures and increased need for additional endoscopic and non-endoscopic interventions. The primary aim of this study was to determine the outcomes of endoscopic ultrasound (EUS)-guided transmural drainage of PFCs in patients with DPDS. In patients undergoing EUS-guided drainage of PFCs from January 2013 to January 2018, demographic profiles, procedural indications and details, adverse events, outcomes, and subsequent interventions were retrospectively collected. Overall treatment success was determined by PFC resolution on follow-up imaging or stent removal without recurrence. EUS-guided drainage of PFCs was performed in 141 patients. DPDS was present in 57 of them (40 %) and walled-off necrosis was the most frequent type of PFC (55 %). DPDS was not associated with lower clinical success, increased number of repeat interventions, or increased time to PFC resolution. Patients with DPDS were more likely to be treated with permanent transmural plastic double-pigtail stents (odds ratio [OR] 6.4; 95 % confidence interval [CI] 2.5 - 16.5; P < 0.001). However, when stents were removed, DPDS was associated with increased PFC recurrence after stent removal (OR 8.0; 95 %CI 1.2 - 381.8; P = 0.04). DPDS frequently occurs in patients with PFCs but does not negatively impact successful resolution. DPDS is associated with increased PFC recurrence after stent removal.

Salvage endoscopic ultrasound-guided rendezvous technique for disconnected pancreatic duct syndrome in a patient with severe acute pancreatitis.

Disconnected pancreatic duct syndrome (DPDS) is characterized by extraductal leakage of pancreatic juice and destruction of tissue surrounding the pancreas [1]. Many DPDS cases need surgical treatment [2]. Transpapillary pancreatic stenting and endoscopic ultrasound (EUS)-guided transmural drainage of PD and walled-off necrosis (WON) are also reported to be effective for DPDS [2] [3] [4]. The EUS-guided rendezvous technique (EUS-RV) was shown to be effective as a salvage procedure to connect to the disruption directly when drainage procedures to treat DPDS proved ineffective.

Importance of Disconnected Pancreatic Duct Syndrome in Recurrence of Pancreatic Fluid Collections Initially Drained Using Lumen-Apposing Metal Stents

Indwelling plastic endoprosthesis in patients with disconnected pancreatic duct syndrome (DPDS) reduces the risk of pancreatic fluid collection (PFC) recurrence. Although lumen-apposing metal stents (LAMS) are used with increasing frequency for PFC drainage, they require timely removal and little is known about their effects in patients with DPDS and recurrence of PFC. We performed a prospective study of patients who underwent endoscopic ultrasound-guided drainage of PFC using LAMS and were found to have DPDS. After resolution of PFC, LAMS were replaced with double-pigtail plastic stents. The primary outcome was to compare PFC recurrence between patients with DPDS who did vs did not receive replacements with plastic stents after removal of the LAMS. Of 188 PFC patients treated with LAMS, 94 had DPDS, 71 had intact pancreatic ducts, and duct patency was unknown in 23. In patients with DPDS, replacement of LAMS with plastic stents was successful in 70 patients (74.5%) and technically unsuccessful in 24 patients (25.5%). At a median follow up of 183 days (interquartile range, 179-188 days), although none of the patients with an intact duct had a recurrence of PFC, 7 of the 94 patients with DPDS had recurrence of PFC (7.4%) (P = .020). PFC recurred in 1 of 70 patients with DPDS in whom replacement of LAMS with plastic stent was successful (1.4%) and in 6 of 24 patients with unsuccessful stent replacement (25.0%) (P = .001). In treatment of PFCs with LAMS in patients with DPDS, it is important to replace the LAMS with indwelling plastic stents to minimize PFC recurrence and reduce morbidity. Clinicaltrials.gov no: NCT02422095.

Disconnected pancreatic duct syndrome – a neglected complication of acute pancreatitis

Disconnected pancreatic duct syndrome – a neglected complication of acute pancreatitis

Sa1451 INTERMEDIATE AND LONG TERM SAFETY OF TRANSMURAL DOUBLE PIG-TAIL PLASTIC STENTS FOR MANAGEMENT OF DISCONNECTED PANCREATIC DUCT SYNDROME AND PANCREATIC DUCT DISRUPTION

Necrotizing pancreatitis and chronic pancreatitis can result in disconnected pancreatic duct syndrome and pancreatic duct disruption which may require long term drainage. Surgical management of these conditions carries high risk for morbidity and mortality. European guidelines recommend long term placement of double pigtail plastic stents (DPPS) however data regarding long term safety of this approach is very limited. This study evaluates long term safety and efficacy of DPPS. A single center retrospective case series was performed at a tertiary referral center. Inclusion criteria were patients who underwent endoscopic ultrasound (EUS) guided placement of DPPS for disconnected pancreatic duct syndrome and pancreatic duct disruption from 1/1/2015 to 8/31/2019. Safety and efficacy of DPPS was assessed with retrospective chart review for complications resulting from DPPS including bleeding, infection, perforation and whether stent spontaneously migrated. Chart review also performed to assess for recurrence of fluid collections, and need for surgical intervention due to failure of DPPS drainage. 38 patients had DPPS placed for long term drainage for disconnected pancreatic duct and pancreatic duct disruption. Median age was 51 years; 65% of subjects were male. Etiology of pancreatitis was idiopathic (14/38) and gallstone (13/38). 21/38 (55%) patients had history of walled of necrosis and 17/38(45%) had pseudocyst. Median length of time stents were left in place was 378 days (range 20-1189). One patient had internal migration of stent which was related to interventional radiology manipulation of a percutaneous drain pulling the DPPS into the necrotic cavity – the DPPS was retrieved with endoscopy. 10 patients had asymptomatic spontaneous luminal migration of DPPS. 2 out of these 10 had recurrent fluid collections that did not require repeat drainage. One patient underwent upsizing of DPPS stent for persistent fluid collection with clinical improvement. There were no serious adverse events related to DPPS including perforation, bleeding, fistulas. No patients needed to have surgical intervention for clinical failure of DPPS. Intermediate and long term placement of indwelling DPPS appears to be a safe and highly efficacious surgery sparing approach for pancreatic duct disruption and disconnected pancreatic duct syndrome with minimal complications and low rate of re-intervention.

Mo1981 ENDOSCOPIC MANAGEMENT OF BLUNT PANCREATIC TRAUMA IN CHILDREN: A RETROSPECTIVE SERIES FROM A LARGE HPB CENTRE

Blunt pancreatic trauma leading to disconnected pancreatic duct syndrome is rare sequelae of blunt pancreatic trauma (incidence 0.2%). Conventionally it is treated surgically with associated morbidity and mortality even in high volume centres. Minimally invasive endoscopic approaches are an attractive alternative, but outcome data is limited. In this study we report a case series from a large HPB centre. Data for all paediatric patients (aged ≤18 years) undergoing endoscopic retrograde cholangiopancreatographies (ERCP), at King’s College Hospital, between January 2008 and December 2018 was collected. ERCPs specifically to manage pancreatic duct (PD) trauma were extrapolated and reviewed. Patient demographics, imaging, endoscopy and outcomes were recorded in each case. Of the 374 children undergoing ERCP, 7.5% (28) had it performed following pancreatic trauma. 21 were male, 7 female; median age 10 (range 5-18) years. Injury occurred following bicycle handle bar trauma in 61% (17), horse riding fall 7, road traffic accident in 2 and unknown in 2. Pre-procedure imaging was with ultrasound in 93% (26), computer topography in 57% (16) and MRCP in 46% (13). The pancreatic duct injury occurred in: pancreatic body 43% (12), the head 36% (10) and the tail 21% (6). 18% (5) of patients had a pancreatic stricture associated with their leak. In total, 70 ERCPs were attempted; median of 2 ERCPs (range 1 – 5) per patient. At the primary ERCP the PD was successfully cannulated in 89% (25), a stent placed across the defect in 36% (9) and a stent left in the proximal duct in a further 56 % (14). 68% (19) patients developed a prolonged PD leak. If a stent was successfully placed across the defect at the primary ERCP patients needed statistically significantly fewer additional ERCPs (1 vs 2, p=0.0165). 7% (2) patients ultimately required pancreatic surgery. Adverse events occurred in 1% (n=1, localised perforation, managed conservatively). Patients were followed up for a median of 12 months (range 3 – 84) from the time of their first ERCP with no long-term sequelae. ERCP with PD stenting is a minimally invasive and effective treatment for the management of blunt pancreatic trauma. Successful stenting across the PD defect at primary ERCP reduces the number of subsequent ERCPs needed. There are no long-term pancreatic complications.

Transgastric Pancreatic Debridement: a Step-by-step Guide to a Single-staged Procedure for Walled-off Pancreatic Necrosis

Treatment of necrotizing pancreatitis (NP) requiring intervention must be tailored to each patient’s individual clinical situation. Surgical transgastric debridement addresses necrosis confined to the lesser sac with the option to perform cholecystectomy in a single intervention.1 With proper patient selection, this technique achieves resolution of necrosis in 90% of patients.2 In the setting of disconnected pancreatic duct syndrome, cystogastrostomy achieves pancreatic tail drainage with durable long-term success in 80% of patients.3 This case presentation and step-by-step walkthrough demonstrates critical technical aspects and decision-making for surgical transgastric debridement of walled-off pancreatic necrosis.

Disconnected pancreatic duct syndrome predicts failure of percutaneous therapy in necrotizing pancreatitis

Background/objectivesMinimally invasive approaches, such as percutaneous drainage (PD), are increasingly utilized as initial treatment in necrotizing pancreatitis (NP) requiring intervention. Predictors of success of PD as definitive treatment are lacking. Our aim was to assess the application, predictors of success, and natural history of PD in NP. We hypothesized that necrosis morphology patterns and disconnected pancreatic duct syndrome (DPDS) may predict the ability of PD to provide definitive therapy. Methods714 NP patients were treated from 2005 to 2018. Patients achieving disease resolution with PD alone (PD) were compared to those requiring an escalation in intervention (Step). Outcomes were compared between groups using independent samples t-test, Fisher’s exact test, and Pearson’s correlation, as appropriate. P < 0.05 was accepted as statistically significant. Results115 patients were initially managed with PD (42 PD, 73 Step). No difference in necrosis morphology was seen between the two groups. The PD group underwent significantly more repeat percutaneous interventions (PD, 3.2; Step, 2.0; P = 0.0006) including additional drain placement and drain upsize/reposition procedures. Patients with DPDS were more likely to require an escalation in intervention (odds ratio, 3.4; 95% confidence interval, 1.5–7.6; P = 0.003). The mean number of months to NP resolution was similar (PD, 5.7; Step, 5.8; P = 0.9). Mortality was similar (PD, 7%; Step 14%, P = 0.3). ConclusionsNecrosis morphology in and of itself does not reliably predict successful definitive treatment by percutaneous drainage. However, patients with disconnected pancreatic duct syndrome were less likely to have definitive resolution with PD alone.

Endoscopic ultrasound-guided pancreatic duct intervention and pancreaticogastrostomy using a novel cross-platform technique with small-caliber devices.

Background and study aims Endoscopic ultrasound (EUS)-guided pancreaticogastrostomy (PG) has been used as an alternative to surgery to drain pancreatic ducts for treatment of disconnected pancreatic duct syndrome (DPDS). Previous techniques involved using needle-knife cautery, bougie dilation or a stent extraction screw to allow stent passage through the gastric wall and pancreatic parenchyma, with potential for severe complications including duct leak, especially if drainage fails. A novel technique employing EUS guided puncture of the main pancreatic duct (MPD) with a 19- or a 22-gauge needle, passage of an 0.018-guidewire, dilation of the tract with a small-diameter (4 F) angioplasty balloon and placement of 3F plastic stents with the pigtail curled inside the duct as an anchor. Methods This is a retrospective case series at a single tertiary center. EUS-guided PG was considered when conventional endoscopic pancreatic duct drainage failed. Main outcomes included technical and clinic success and complications. Results Eight patients underwent PG. Indications were DPDS (n = 4), stenotic pancreaticoenteral anastomosis after Whipple procedure (n = 3) and chronic pancreatitis with dilated MPD (n = 1). Median MPD diameter was 6.75 mm [IQR 2.8 – 7.6]. Technical success was achieved in seven of eight cases (88 %); angioplasty balloon passed into the pancreatic duct in all accessed ducts. There was one asymptomatic duct leak, and no major or delayed complications, with clinical improvement (complete or partial) in five of eight (71 %). Conclusions EUS-guided PG using a small-caliber guidewire, 4F angioplasty balloon, and reverse 3F single pigtail stents offers a safe and atraumatic alternative without use of cautery.

Clinical and morphological consequences of permanent indwelling transmural plastic stents in disconnected pancreatic duct syndrome.

Background:Long-term indwelling transmural stents in patients with walled-off necrosis (WON) and disconnected pancreatic duct syndrome (DPDS) is an effective strategy to decrease risk of recurrence of pancreatic fluid collection (PFC). However, long-term studies on the safety and efficacy of this strategy are lacking.Methods:Retrospective analysis of database of patients with WON treated with endoscopic transmural drainage over the past 8 years was done to identify patients with DPDS and indwelling transmural stents for >3 years.Results:During the past 8 years, 56 patients with indwelling transmural stent for >3 years were identified and 67.85% of these patients had 10 Fr stents and 32.15% of patients had 7 Fr stents. On follow-up, 5 (8.9%) patients had pancreatic pain with one patient (1.78%) developing recurrence of PFC despite stent being in situ. Two (3.5%) patients had asymptomatic spontaneous external migration of the transmural stent. Fourteen (25%) patients developed diabetes. Two (3.5%) patients developed local complications due to indwelling stent (stent eroded into descending colon in one patient and stent-induced parenchymal calcification in the other). Forty-eight (85.7%) patients underwent EUS on follow-up and disconnected pancreas revealed ≥5 criteria for the diagnosis of chronic pancreatitis in 15 (31.25%) patients.Conclusions:Long-term indwelling transmural plastic stents in patients with WON and DPDS are safe and effective with minimal complications. Despite the presence of stents, disconnected pancreas develops morphological changes resembling chronic pancreatitis in one-third patients and clinical consequences of these changes need to be further evaluated.

Diagnosis of disrupted and disconnected pancreatic duct in acute pancreatitis: a systematic review

Background: Necrotizing pancreatitis may result in disrupted or disconnected pancreatic duct syndrome, which can lead to several complications. Diagnosis of disconnected pancreatic duct syndrome is not standardized in clinical practice and international guidelines. We therefore performed a systematic review of the current literature on imaging modalities for diagnosing disrupted or disconnected pancreatic duct syndrome in patients with acute pancreatitis. Methods: A systematic search was performed in MEDLINE, Embase and Cochrane library databases up to October 2018 to identify all studies evaluating diagnostic modalities for the diagnoses of disconnected pancreatic duct syndrome in acute pancreatitis. All data regarding diagnostic accuracy were extracted. Results: We included twelve studies, evaluating 286 relevant patients, reporting on five different diagnostic modalities. One study evaluated endoscopic retrograde cholangiopancreatography (ERCP) compared with surgical confirmed disruption, showing a sensitivity of 100%. This was equal to the sensitivity found, in a selective study population, for endoscopic ultrasound (EUS) in detecting a disrupted pancreatic duct. The sensitivity of (secretin)-magnetic resonance cholangiopancreatography (MRCP), as compared with several other diagnostic modalities, ranged from 83.3%-100% and a specificity of 100%. With a sensitivity of 83.3% and specificity of 100% for secretin-MRCP alone. The overall diagnostic accuracy of amylase-measurement in drain fluids for detecting a disrupted pancreatic duct was 65%, with a sensitivity of 100% and a specificity of 50%. The sensitivity for computed tomography was 68%. Conclusion: This systematic review suggests that EUS, ERCP and (secretin)-MRCP are all accurate in diagnosing a disruption or disconnection of the pancreatic duct in patients with acute pancreatitis. Given the poor overall visualization of the pancreatic duct on EUS and the invasive nature of ERCP, however, (secretine)-MRCP is recommended as first diagnostic modality. Further prospective studies are needed to define the optimal timing and diagnostic value of (secretin)-MRCP in different subgroups of patients with necrotizing pancreatitis.

Natural course of low output external pancreatic fistula in patients with disconnected pancreatic duct syndrome following acute necrotising pancreatitis

BackgroundExternal pancreatic fistulae (EPF) associated with complete pancreatic duct (PD) disruption leading on to disconnected pancreatic duct syndrome (DPDS) is a therapeutic nightmare usually requiring surgery. However, spontaneous closure also has been reported. There is paucity of data on the natural history of EPF associated with DPDS. ObjectiveTo retrospectively study outcome of conservative treatment in patients with low output (<200 ml/day) EPF with DPDS following percutaneous or surgical intervention in acute necrotising pancreatitis (ANP). MethodsThe data of patients of low output EPF with DPDS treated conservatively in our unit over last 5 years was retrospectively analysed. Their clinical course, complications as well as time taken for fistula closure was retrieved. Results33 patients (27 males; mean age: 40.5 ± 9.3 years) of low output EPF and DPDS were studied. 31 patients developed EPF following percutaneous drainage (PCD) and 2 patients developed fistula following surgery. The drain fluid amylase ranged from 1600 to 32,000 IU/l and site of disruption was neck, proximal body and distal body in 4, 16 and 13 patients respectively. EPF closed spontaneously in all patients within 88.2 ± 63.46 days. PCD slipped out in 2 patients and led to formation of pseudocyst in 1 patient that was treated endoscopically. There has been no recurrence in any patient over follow up of 32.5 ± 21.9 months. ConclusionLow output EPF developing post PCD or surgery in patients with DPDS following ANP closely spontaneously in majority of patients within 3 months with good long term outcome.

Disconnected Pancreatic Duct Syndrome: Spectrum of Operative Management

BackgroundDisconnected pancreatic duct syndrome (DPDS) is common after necrotizing pancreatitis (NP). Surgical management may be by internal drainage or left (distal) pancreatectomy. Therapeutic decision-making must consider sinistral portal hypertension, parenchymal volume of disconnected pancreas, and timing relative to definitive management of pancreatic necrosis. The aim of this study is to evaluate outcomes after operative management for DPDS. MethodsAll patients with NP undergoing an operation for DPDS were included in the study (2005-2017). Perioperative outcomes and long-term durability were evaluated. ResultsAmong 647 patients with NP, 299 (46%) had DPDS. Operative management was required in 202/299 (68%) patients with DPDS. Median follow-up was 30 mo (2-165). Definitive operative therapy included internal drainage (n = 111) or resection (n = 91). Time from NP diagnosis to operation was 126 d (20 d to 81 mo). Overall morbidity was 46%. Postoperative length of stay was 7 d (2-97). Readmission was required in 39 patients (19%). Mortality was 2%. Repeat pancreatic intervention was required in 23 patients (11%) at a median of 15 mo (1-98). Repeat pancreatectomy was performed in nine patients and the remaining 14 patients were managed with endoscopic therapy. ConclusionsDPDS is a common and challenging consequence of NP. Appropriate operation is durable in nearly 90% of patients.

1300 Disconnected Pancreatic Duct Syndrome a Rare Complication

INTRODUCTION: What follows is a case study of a patient with a pancreatic pseudocyst who developed a complication of Disconnected Pancreatic Duct Syndrome (DPDS). Pseudocysts are a collection of fluid and tissue that forms as result of trauma or repeated spells of pancreatitis. A rare complication of these cysts is disruption of the pancreatic duct termed (DPDS). This case report will discuss the diagnosis and management DPDS along with highlighting the use of endoscopic stenting for the management. CASE DESCRIPTION/METHODS: The patient is a 49-year-old male who presented to the hospital with sudden onset epigastric pain and distention. His past medical history includes chronic pancreatitis, and alcoholic cirrhosis with ascites, requiring large volume paracenteses. On admission, the patient's physical exam was remarkable for diffuse abdominal tenderness and ascites. Labwork was significant for a lipase of 329 U/L, albumin of 2.5 U/L, and a hemoglobin of 8.4 g/dL. Given the patient's abdominal tenderness, a paracentesis was performed with a resulting cell count concerning for Spontaneous Bacterial Peritonitis. A week later, patient had marked improvement in his abdominal exam. However, a CBC drawn on day 7 revealed a hemoglobin of 6.9 g/dL. A CT scan was ordered revealing an 8 cm inflammatory mass/pseudocyst in the head of the pancreas compressing the main portal vein. Another paracentesis was performed which showed high amylase consistent with a pancreatic source. Given these findings, GI performed a magnetic resonance cholangiopancreatography which showed pancreatic duct disconnection complicated by a large 6.4 × 5.5 cm cystic collection at the pancreatic head. An ERCP was performed with the implementation of a lumen apposing stent. DISCUSSION: DPDS is usually diagnosed with contrast enhanced CT which shows an absence of the pancreatic neck, body or tail. ERCP is usually able to show cut-off of the pancreatic duct or extravasation of contrast. ERCP with stenting is one minimally invasive intervention that has shown to reduce the recurrence rate of fluid collection. There are two challenges that are commonly encountered: high rates of stent migration and inability to pass a stent between the two disconnected ends of the duct. Due to the fact that there is still a lot that is not known about this disease state the consensus on optimal management remains to be determined. DPDS is a disease state that can be difficult to manage which is why early identification is the mainstay of successful treatment.

Disrupted Pancreatic Duct Syndrome: An Evolving Challenge that Calls for Innovative Approach

Disrupted Pancreatic Duct Syndrome: An Evolving Challenge that Calls for Innovative Approach

Disconnected Pancreatic Duct in Children With Walled OFF Necrosis: Impact on Outcomes of Endoscopic Drainage.

Disconnected pancreatic duct syndrome (DPDS) is frequently encountered in cases with walled off necrosis (WON). The impact of DPDS on the outcomes of pancreatic fluid collections (PFCs) is not well known. In this study, we aim to evaluate the incidence of DPDS and its clinical impact on the outcomes of endoscopic ultrasound (EUS)-guided drainage of PFC in children. All children with symptomatic WON who underwent EUS-guided drainage using metal stents were included in the study. At 4 weeks, pancreatic ductal anatomy was evaluated, and metal stents removed. All the children were followed at regular intervals and evaluated for the recurrence of PFC and the development of new-onset diabetes. A total of 32 children (28 boys, median age 15 years) underwent EUS-guided drainage of WON. Resolution of WON was documented in all children at 4 weeks. Pancreatic ductal anatomy using magnetic resonance retrograde cholangiopancreatography and endoscopic retrograde pancreatography was available in 30 (93.7%) children. Of these, DPDS was documented in 25 (83.3%) children including proximal disconnection in 12 and distal disconnection in 13 children. Recurrent PFC and new-onset diabetes were found in 5 (20%) and 2 (8%) children with DPDS, respectively. Of the 5 recurrences of PFC, endoscopic reintervention was required in 3 children. Majority of the children with DPDS do not develop a symptomatic recurrence of PFC after the removal of cystogastric stents. DPDS may be a risk factor for the development of new-onset diabetes. However, future prospective studies are needed.

892 DISCONNECTED PANCREATIC DUCT SYNDROME AFFECTS ENDOSCOPIC MANAGEMENT OF PANCREATIC FLUID COLLECTIONS

Endoscopic transmural drainage is routinely performed for treatment of symptomatic pancreatic fluid collections (PFCs). Limited data suggest that disconnected pancreatic duct syndrome (DPDS) results in more primary failures of endoscopic therapy with an increased need for percutaneous drainage. This study aims to determine the impact of DPDS on endoscopic management of PFCs.