Endoscopic management of pancreatic fluid collections with disconnected pancreatic duct syndrome

Abstract

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

Keywords: disconnected pancreatic duct syndrome; necrotizing pancreatitis; pancreatic fluid collections; pancreatic pseudocysts; walled-off necrosis.

Figure 1

ERCP images of disconnected pancreatic duct syndrome. (a) Complete pancreatic duct disruption in a patient with traumatic pancreatic injury: ERCP reveals total cutoff of proximal main pancreatic duct with opacification of Santorini duct. (b) Complete pancreatic duct disruption in a patient with acute necrotizing pancreatitis: ERCP reveals total cutoff at the body of the pancreas, without visualization of the pancreatic tail. (c) Complete pancreatic duct disruption in a patient with severe acute pancreatitis: ERCP reveals contrast extravasation from proximal main pancreatic duct, without visualization of the main pancreatic duct at the body or tail

Figure 2

Contrast-enhanced computed tomography scans and magnetic resonance cholangiopancreatography of disconnected pancreatic duct syndrome in a patient with acute necrotizing pancreatitis. (a) Contrast-enhanced computed tomography done after the resolution of walled-off pancreatic necrosis reveals dilated distal pancreatic duct (white arrow) and abrupt cutoff at the neck of the pancreas (black arrow). (b) Contrast-enhanced computed tomography also reveals a necrotic area (black arrow) at the neck of the pancreas at the same time. (c) Follow-up contrast-enhanced computed tomography 4 months later reveals a recurrent huge pseudocyst, with viable and atrophic but disconnected upstream pancreatic tissue (white arrow). (d) Follow-up magnetic resonance cholangiopancreatography reveals the huge pseudocyst and dilated distal pancreatic duct (white arrow)

Figure 3

Transmural drainage performed in patients of pancreatic fluid collections with disconnected pancreatic duct syndrome. (a) Fluoroscopic image showing lumen-apposing metal stents was placed across transmural tract. (b) Endoscopic views showing lumen-apposing metal stents deployment in the stomach. (c) Fluoroscopic image showing two double-pigtail plastic stents were placed. (d) Endoscopic views showing two transmural plastic stents deployment in the stomach