Clinical outcomes of long-term transmural drainage with double pigtail stents in disconnected pancreatic duct syndrome

Abstract

Background: Disconnected pancreatic duct syndrome (DPDS) is a common cause of recurrent pancreatic fluid collections (PFCs), often requiring repeat drainage. Following initial drainage with lumen apposing metal stents (LAMS), replacement with transmural double pigtail stents (DPS) has been shown to be a viable drainage modality mitigating the risk of recurrence. The sparsity of literature on the consequences of this strategy requires further investigation. We analyze our outcomes of long-term transmural drainage with DPS in patients with DPDS and assess the safety and efficacy of this technique.

Methods: This retrospective review of a prospectively maintained database from November 2015-May 2022 included all patients with DPDS who underwent removal of LAMS and replacement with long-term transmural DPS. Patient demographics, collection characteristics, drainage technique and outcomes, as well as follow-up data was collected and analyzed using descriptive statistics.

Results: There were 139 patients who underwent endoscopic drainage of PFCs with LAMS during the study period. Seventy-eight patients [walled-off necrosis (n=65) and pseudocysts (n=13)] were found to have DPDS. Of these, 44 patients underwent successful LAMS removal followed by replacement with DPS and were included in the analysis. The median age was 57 years and 14 (32%) were female. The median stent dwell time was 394 days [interquartile range (IQR) 245, 853 days]. Spontaneous stent migration was seen in seven patients (16%), one of whom developed a PFC recurrence which was managed conservatively. The second recurrence was seen in a patient with indwelling DPS which did not require further intervention. There were no locoregional adverse events secondary to long-term indwelling DPS. Among the 28 patients who were followed for a year, three patients developed new-onset diabetes, and chronic pancreatitis (CP) changes in the disconnected segment were seen in eight patients, five of whom required pancreatic enzyme supplementation.

Conclusions: Placement of long-term transmural DPS is an effective modality for preventing collection re-accumulation with a favorable safety profile. Randomized prospective studies are essential to investigate the optimal removal timing of indwelling stents to prevent loco-regional complications. Given the realized risk of CP in the disconnected pancreas, follow-up cross sectional imaging may help guide further therapy.

Keywords: Disconnected pancreatic duct syndrome (DPDS); double pigtail stents (DPS); lumen apposing metal stents (LAMS); pancreatic fluid collections (PFCs).

Figure 1

Magnetic resonance cholangiopancreatography showing a pancreatic fluid collection with loss of ductal integrity in the body of pancreas indicative of disconnected pancreatic duct syndrome. CBD, common bile duct; PD, pancreatic duct.

Figure 2

Endoscopic ultrasound guided drainage of pancreatic fluid collection using lumen apposing metal stent with subsequent replacement with double pigtail stents for long term transmural drainage for disconnected pancreatic duct syndrome. (A) Endoscopic ultrasound showing a pancreatic fluid collection. Echogenic contents can be seen within the collection (yellow asterisk). (B) Balloon dilation of lumen apposing metal stent to 15 mm under endoscopic and fluoroscopic guidance following cystgastrostomy. (C) Endoscopy at 3 weeks showing healthy appearing cyst wall with no necrotic material. (D) Fluoroscopic image showing lumen apposing metal stent removal and placement of two double pigtail plastic stents for long term transmural drainage.

Figure 3

Clinical outcomes of patients with disconnected pancreatic duct syndrome. PFCs, pancreatic fluid collections; DPDS, disconnected pancreatic duct syndrome; LAMS, lumen apposing metal stents; DPS, double pigtail stent; EPI, exocrine pancreatic insufficiency; DM, diabetes mellitus.