Endoscopic transmural drainage is associated with improved outcomes in disconnected pancreatic duct syndrome: a systematic review and meta-analysis.

BACKGROUND: Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aimed to review the definitions, clinical presentation, intervention, and outcomes for DPDS. METHODS: The PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites. RESULTS: Thirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.3%, 936/982), followed by chronic pancreatitis (3.1%, 30/982). DPDS commonly presented with PFC (83.2%, 948/1140) and EPF (13.4%, 153/1140). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI 81.0-95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7-77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6-90.5) and 87.4% (95%-CI 81.2-91.8), respectively (P = 0.389). CONCLUSIONS: Endoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research.

Efficacy of early endoscopic intervention in pediatric pancreatic duct injury management.

BACKGROUND: The optimal management method for pediatric pancreatic trauma is controversial. Moreover, the efficacy of stent placement via endoscopic retrograde pancreatography (ERP) remains poorly documented. METHODS: The present, retrospective review of pediatric patients with pancreatic trauma was conducted from 2010 to 2020 at a single institution. RESULTS: Ten, male children with the median age of 9.5 years (range 4-14 years) with a grade I (n = 2), II (n = 4) or III (n = 4) pancreatic injury were identified. Of six of these patients in whom ERP was performed, four had a pancreatic duct injury (PDI). Pancreatic stent placement was performed in all the patients with ERP at a site proximal to the injury in four patients and across the injury in two patients. A pseudocyst or pancreatic fluid collection was detected in five patients, of these, two with a grade II injury were managed successfully with conservative therapy while three with PDI required surgery. In the four patients with PDI, only one in whom the stent was placed across the PDI was able to avoid surgery. CONCLUSION: Therapeutic ERP might be effective even if a patient has a PDI, therefore, early ERP should be considered as a treatment option.

The role of endoscopic treatment of pancreatic duct disruption in patients with walled-off pancreatic necrosis.

BACKGROUND: The place of endoscopic techniques in the treatment of main pancreatic duct (MPD) disruption arising in the course of acute necrotizing pancreatitis (ANP) remains unclear. The aim of this study was to describe the findings of endoscopic retrograde pancreatography (ERP) in patients with walled-off necrosis (WON). It was attempted to evaluate the role of endoscopic treatment of pancreatic duct disruption in patients with WON. METHODS: The retrospective analysis of results and complications with particular emphasis to all ERP procedures in the group of 226 patients was conducted, which underwent endoscopic treatment of symptomatic WON between years 2001 and 2016 in the Department of Gastroenterology and Hepatology of Medical University of Gdansk. RESULTS: ERP was performed in 204/226 (90.27%) patients. Partial and complete disruption of the MPD were identified in 103 (50.49%) and 63 (30.89%) out of 204 patients, respectively. Endoscopic treatment was used in all 166 patients with MPD disruption. The success of endoscopic treatment of MPD disruption was achieved in 138/161 (85.71%) patients with WON. The therapeutic success of WON endotherapy was achieved in 214/226 (94.69%) patients. The mean follow-up duration was 56 (SD = 37.06) [range 14-158] months. Long-term success of treatment of WON was achieved in 182/226 (80.53%) patients. CONCLUSIONS: MPD disruption occurs in the majority of patients with WON. Partial disruption of the MPD is more frequent than complete disruption of the duct. This study conducted on a large group of patients demonstrated that prosthesis insertion into the MPD in patients with disruption of the MPD in the course of ANP is one of the key elements in endoscopic treatment of WON. Passive transpapillary drainage is an effective method of treating MPD disruptions, which improves long-term outcomes of endoscopic treatment in patients with WON.

The role of transpapillary drainage in management of patients with pancreatic fluid collections and pancreatic duct disruption as a consequences of severe acute pancreatitis.

In last thirty years we have been observing significant development of an endoscopic treatment of pancreatic fluid collections, including transmural drainage of walled-off pancreatic necrosis. Simultaneously, the use of endotherapy in treatment of main pancreatic ducts disruptions has increased. Despite many publications available in current literature, concerning the endoscopic treatment of consequences of acute necrotizing pancreatitis, the role of transpapillary drainage in management of patients with pancreatic fluid collections and pancreatic duct disruption as an after-effect of severe acute pancreatitis remains unclear and is still a current problem. This publication includes comment on the article entitled 'Early dual drainage combining transpapillary endotherapy and percutaneous catheter drainage in patients with pancreatic fistula associated with severe acute pancreatitis' published by Yokoi et al. in the July-August 2016 issue of Pancreatology together with questions to the authors. Furthermore, in the article we did pay particular attention to the role of transpapillary drainage in management of pancreatic fluid collections, especially of walled-of pancreatic necrosis.

Early dual drainage combining transpapillary endotherapy and percutaneous catheter drainage in patients with pancreatic fistula associated with severe acute pancreatitis.

BACKGROUND: The development of pancreatic fistula (PF) associated with pancreatic necrosis is of great concern in the management of severe acute pancreatitis (SAP). We expected that early recognition and intervention of PF combined with percutaneous catheter drainage (PCD) for pancreatic infection may improve SAP outcomes. METHODS: Fifteen consecutive patients with SAP were enrolled. Whenever feasible, fine-needle aspiration for fluid collection was performed to determine infection and amylase concentration. For infection and PF with amylase-rich fluid, PCD and transpapillary endotherapy (preferably naso-pancreatic drainage) were carried out as soon as possible. PCD was intensively managed by irrigating the sized-up and multiple large bore catheters. RESULTS: Infected fluid collection and PF were both detected in 13 (86.7%) patients. Pancreatic duct (PD) disruption (n = 6) and organ failure (n = 5) occurred exclusively in patients with amylase-rich collection ≥10,000 U/L. The median timing of PCD and endotherapy was 15.5 and 16.5 days, respectively. No serious complications or mortality resulted from intervention procedures other than stent occlusion in one (6.7%) patient. Surgical intervention due to uncontrollable infection and visceral organ injury was avoided. Fistula closure was achieved in 12 (92.3%) of 13 PF patients with a median duration of 45 days. Disease-related mortality occurred in one (6.7%) patient. CONCLUSION: Amylase-rich fluid collection ≥10,000 U/L may be an indication for further endoscopic investigation of PD disruption. Early dual drainage combining pancreatic endotherapy and PCD is feasible and safe, and may improve treatment outcome.

Management of Disconnected Pancreatic Duct.

Disconnected pancreatic duct (DPD) is common after acute necrotizing pancreatitis (ANP). Its clinical implications vary according to the course of disease. In the early phase of ANP, parenchymal necrosis along with disruption of pancreatic duct cause acute necrotic collection that evolves into walled-off necrosis (WON). In the later phase, DPD becomes evident as confirmed by magnetic resonance cholangiopancreatography. Clinical manifestations of DPD can vary from being asymptomatic, recurrent pain, recurrent pancreatic fluid collection (PFC), obstructive pancreatitis, or external pancreatic fistula (EPF). Few patients develop new-onset diabetes. Long-term indwelling plastic stents have been proposed to prevent the recurrent PFC.

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.

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

Background: 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. Methods: 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. Results: 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. Conclusion: 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.

Spontaneous regression of asymptomatic walled-off pancreatic necrosis.

INTRODUCTION: Asymptomatic walled-off pancreatic necrosis (WOPN) should be treated conservatively, irrespective of the extent and size of the necrosis. The aim of this study was to evaluate the efficacy and safety of a strategy involving the observation of patients with asymptomatic WOPN over a long period of time. MATERIAL AND METHODS: This study involved the retrospective analysis of 368 patients hospitalized in our department between 2010 and 2016, due to acute pancreatitis and its consequences in the form of pancreatic and peripancreatic fluid collection. RESULTS: Walled-off pancreatic necrosis was identified in 168/368 (46%) patients. 124/168 (74%) patients with WOPN required interventional treatment due to clinical symptoms arising from the presence of the WOPN. Asymptomatic WOPN was identified in 44/168 (26%) patients. The mean observation time of patients with asymptomatic WOPN was 417.02 days (range: 47-1149 days). Only 1 out of the 44 patients (2%) failed to complete the follow-up. Complete regression of WOPN occurred in 30/44 (68%) patients. The presence of symptoms related to WOPN were identified in 13/44 (30%) patients during the observation. The most frequent indication for interventional treatment of WOPN was infection of the pancreatic necrosis, which was identified in 6/13 patients (46%). Altogether, 137/168 (82%) patients with WOPN required interventional treatment. CONCLUSIONS: The majority of patients with WOPN required interventional treatment. This study provided evidence to support the view that careful observation of patients with asymptomatic WOPN is an efficient and safe treatment strategy. Long-term observation of such patients showed that most will experience spontaneous regression of asymptomatic WOPN without any other form of interventional treatment.

Fistulojejunostomy Versus Distal Pancreatectomy for the Management of the Disconnected Pancreas Remnant Following Necrotizing Pancreatitis.

BACKGROUND: A disconnected distal pancreas (DDP) remnant is a morbid sequela of necrotizing pancreatitis. Definitive surgical management can be accomplished by either fistulojejunostomy (FJ) or distal pancreatectomy (DP). It is unclear which operative approach is superior with regard to short- and long-term outcomes. METHODS: Between 2002 and 2014, patients undergoing either FJ or DP for DDP were retrospectively identified at a center specializing in pancreatic diseases. Patient demographics, perioperative, and postoperative variables were evaluated. RESULTS: Forty-two patients with DDP secondary to necrotizing pancreatitis underwent either a FJ (n = 21) or DP (n = 21). Between the two cohorts, there were no significant differences in overall lengths of stay, pancreatic leak rates, or readmission rates (all p > 0.05). DP was associated with higher estimated blood loss, increased transfusion requirements, and worsening endocrine function (all p < 0.05). At a median follow-up of 18 months, four patients that underwent a FJ developed a recurrent fluid collection requiring re-intervention. Overall, FJ was successful in 80% of patients as compared to a 95% success rate for DP (p = 0.15). CONCLUSIONS: Although DP was associated with higher intraoperative blood loss, increased transfusion requirements, and worsening of preoperative diabetes, this procedure provides superior long-term resolution of a DDP when compared to FJ.

Dual drainage using a percutaneous pancreatic duct technique contributed to resolution of severe acute pancreatitis.

A 66-year-old man was admitted for severe acute alcoholic pancreatitis with infected pancreatic necrosis (IPN). Abdominal computed tomography revealed an inflamed pancreatic head, a dilated main pancreatic duct (MPD), and a large cavity with heterogeneous fluid containing gas adjacent to the pancreatic head, and extending to the pelvis. The cavity was drained percutaneously near the pancreatic head on admission; another tube was inserted into the pelvic cavity on hospital day 3. The drained fluid contained pus with high amylase concentration. Nasopancreatic drainage tube placement was unsuccessfully attempted on hospital day 9. On hospital day 23, percutaneous puncture of the MPD and placement of a pancreatic duct drainage tube was performed. Pancreatography revealed major extravasation from the pancreatic head. The IPN cavity receded; the percutaneous IPN drainage tube was removed on hospital day 58. On hospital day 83, the pancreatic drainage was changed to a transpapillary pancreatic stent, and the patient was discharged. Measuring the amylase concentration of peripancreatic fluid collections can aid in the diagnosis of pancreatic duct disruption; moreover, dual percutaneous necrotic cavity drainage plus pancreatic duct drainage may be essential for treating IPN. If transpapillary drainage tube placement is difficult, percutaneous pancreatic duct drainage may be feasible.

Severe Acute Pancreatitis with Complicating Colonic Fistula Successfully Closed Using the Over-the-Scope Clip System.

A 44-year-old man presenting to our hospital emergency room with abdominal pain was hospitalized for hyperlipidemic acute pancreatitis. A pig-tail catheter was placed percutaneously to drain an abscess on day 22. Although the abscess improved gradually and good clinical progress was seen, pancreatic duct disruption was strongly suspected and endoscopic retrograde cholangiopancreatography was performed on day 90. An endoscopic nasopancreatic drainage tube was placed, but even with concurrent use of a somatostatin analogue, treatment was ineffective. Surgical treatment was elected, but was subsequently postponed as the abscess culture was positive for extended-spectrum ß-lactamase-producing Escherichia coli and methicillin-resistant Staphylococcus aureus. Drainage tubography showed a small fistula of the colon at the splenic flexure on day 140. Colonoscopy was performed on day 148. After indigo carmine had been injected, a fistula into the splenic flexure of the colon showed blue staining. The over-the-scope clip (OTSC) system was used to seal the fistula and complete closure was shown. A liquid diet was started on day 159 and was smoothly upgraded to a full diet. Following removal of the pancreatic stent on day 180, drainage volume immediately decreased and the percutaneous drain was removed. On day 189, computed tomography showed no exacerbation of the abscess and the patient was discharged on day 194. This case of colonic fistula caused by severe acute pancreatitis was successfully treated using the OTSC system, avoiding the need for an open procedure.