Diagnosis and impact of disconnected pancreatic duct syndrome on endoscopic management of pancreatic fluid collections

Bang JY, Wilcox CM, Navaneethan U, Hasan MK, Peter S, Christein J, et al. Impact of disconnected pancreatic duct syndrome on the endoscopic management of pancreatic fluid collections. Ann Surg 2016. [Epub ahead of print].

This study reports findings of a retrospective evaluation of a database of patients from two large tertiary care centers in the USA with extensive experience in pancreatic endotherapy undergoing endoscopic drainage for pancreatic fluid collections (PFCs) from 2003 to 2015. The patients underwent an initial endoscopic/endoscopic ultrasound-guided (EUS) drainage, and if the response was deemed inadequate, further intervention in the form of multi-gate technique, dual modality drainage, or percutaneous necrosectomy was undertaken for clinical success. The authors report about the presence of disconnected pancreatic duct syndrome (DPDS) and its implication on outcome vis-à -vis success of intervention, requirement of hybrid methods or repeated interventions, length of hospitalization, requirement for surgery, etc. The diagnosis of DPDS was based on magnetic resonance cholangiopancreatography (MRCP) (eighty patients) or endoscopic retrograde cholangiopancreatography (ERCP) (180 patients) or EUS-guided pancreatogram (four patients) findings. Any patient requiring more than six endoscopic procedures was deemed to have failed treatment. While till 2008 no transmural stents were left, after 2008, transmural stents were left in situ to allow for the drainage of disconnected segment of the pancreas.

In a cohort of 361 patients, seventy patients could not be assessed for the presence of DPDS due to various reasons. Of the rest of 291 patients, 167 patients had DPDS while 124 had the continuity of the MPD maintained. The patients with DPDS were older than the other group and had a larger number of male patients with walled-off pancreatic necrosis (WON)-type collections which were larger or multiple in numbers. The drainage in DPDS patients was more likely to be trans-duodenal and required placement of a larger number of stents. These patients also needed enteral feeding tube placement more frequently because of a poor tolerance to orally administered feeds. Overall, 88% of patients achieved treatment success and these rates were similar in patients with or without DPDS. However, the presence of DPDS was associated with more requirements of additional (hybrid) procedures which were needed in one-third of the patients in contrast to being needed in only 4.8% of patients without DPDS. Endoscopic re-interventions were needed more frequently in patients who had an underlying DPDS vis-à -vis those who did not have DPDS (30% and 18.5%, respectively). Moreover, the need for surgical intervention for rescue of failed endoscopic therapy was also significantly higher in patients with DPDS as compared to patients without DPDS (13.2 vs. 4.8%, respectively). The median duration of hospitalization was also longer in the patients with DPDS by a day (3 vs. 2 days). However, the recurrence of PFCs was not different among the two groups. However, among the patients with DPDS, the recurrence rates were significantly lower for patients with permanent indwelling transmural stents. Other than the presence of DPDS, presence of WON and collections more than 10 cm was also associated with the need for hybrid procedures. The authors concluded that DPDS significantly impacts the endoscopic management of PFCs with requirement of more complex and frequent endoscopic interventions with higher failure rates.

• References

• 1 Sharma V, Rana SS, Bhasin DK. Endoscopic ultrasound guided interventional procedures. World J Gastrointest Endosc 2015; 7: 628-42
• 2 Varadarajulu S, Rana SS, Bhasin DK. Endoscopic therapy for pancreatic duct leaks and disruptions. Gastrointest Endosc Clin N Am 2013; 23: 863-92
• 3 Pelaez-Luna M, Vege SS, Petersen BT, Chari ST, Clain JE, Levy MJ. et al Disconnected pancreatic duct syndrome in severe acute pancreatitis: Clinical and imaging characteristics and outcomes in a cohort of 31 cases. Gastrointest Endosc 2008; 68: 91-7
• 4 Rana SS, Bhasin DK, Rao C, Sharma R, Gupta R. Consequences of long term indwelling transmural stents in patients with walled off pancreatic necrosis and disconnected pancreatic duct syndrome. Pancreatology 2013; 13: 486-90
• 5 Téllez-Ávila FI, Casasola-Sánchez LE, Ramírez-Luna Mà, Saúl à, Murcio-Pérez E, Chan C. et al Permanent indwelling transmural stents for endoscopic treatment of patients with disconnected pancreatic duct syndrome: Long-term results. J Clin Gastroenterol 2016 [Epub ahead of print]
• 6 Rana SS, Bhasin DK, Sharma R, Gupta R. Factors determining recurrence of fluid collections following migration of intended long term transmural stents in patients with walled off pancreatic necrosis and disconnected pancreatic duct syndrome. Endosc Ultrasound 2015; 4: 208-12
• 7 Rana SS, Sharma R, Sharma V, Chhabra P, Gupta R, Bhasin DK. Prevention of recurrence of fluid collections in walled off pancreatic necrosis and disconnected pancreatic duct syndrome: Comparative study of one versus two long term transmural stents. Pancreatology 2016; 16: 687-8
• 8 Ang TL, Kongkam P, Kwek AB, Orkoonsawat P, Rerknimitr R, Fock KM. A two-center comparative study of plastic and lumen-apposing large diameter self-expandable metallic stents in endoscopic ultrasound-guided drainage of pancreatic fluid collections. Endosc Ultrasound 2016; 5: 320-7
• 9 Fischer TD, Gutman DS, Hughes SJ, Trevino JG, Behrns KE. Disconnected pancreatic duct syndrome: disease classification and management strategies. J Am Coll Surg 2014; 219: 704-12