Endoscopy 2018; 50(07): E188-E189
DOI: 10.1055/a-0605-3076
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Disconnected pancreatic duct syndrome – Wait! Why not try one more time?

Shu-Ling Wang*
Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
,
Sheng-Bing Zhao*
Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
,
Tian Xia
Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
,
Zhao-Shen Li
Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
,
Yu Bai
Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
› Author Affiliations
Further Information

Publication History

Publication Date:
12 June 2018 (online)

A 42-year-old man with a history of necrotizing pancreatitis complicated by pancreatic fluid collections (PFCs) who underwent percutaneous drainage for 4 months but still had a persistent external fistula with high amylase activity in the drainage fluid was referred. A previous endoscopic retrograde cholangiopancreatography (ERCP) in another endoscopy center had suggested complete main pancreatic duct (MPD) disruption ([Fig. 1]). Contrast injection through the drainage catheter showed no opacification of the proximal MPD ([Fig. 2 a]). During a second ERCP, carried out in our endoscopy center, contrast injection through the major duodenal papilla also demonstrated complete cutoff of the proximal MPD and no opacification of the distal MPD ([Fig. 2 b]). Therefore, the diagnosis of complete MPD disruption was made and normally surgical treatment would have been considered.

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Fig. 1 Image from an endoscopic retrograde cholangiopancreatography performed at another endoscopy center suggesting there was complete main pancreatic duct disruption.
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Fig. 2 Radiographic images showing: a no opacification of the proximal main pancreatic duct (MPD) on contrast injection through the drainage catheter; b complete cutoff of the proximal MPD and no opacification of the distal MPD on contrast injection through the major duodenal papilla; c a pancreatic stent placed to drain the pancreatic fluid collections.

Fortunately, in this case, after several attempts by the endoscopist, the disruption site was traversed with a guidewire, and the route from the MPD complete cutoff to the site of the PFCs was not opacified by any contrast. A pancreatic stent was placed to drain the PFCs ([Fig. 2 c] and [Fig. 3]; [Video 1]) and immediately there was cessation of fluid drainage from the percutaneous drainage catheter. The patient had an uneventful recovery and was discharged 1 day later, with surgery having been avoided.

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Fig. 3 Endoscopic image showing pancreatic juice draining through the stent.

Video 1 Endoscopic retrograde cholangiopancreatography treatment of disconnected pancreatic duct syndrome.


Quality:

The diagnosis of disconnected pancreatic duct syndrome (DPDS) is usually confirmed on ERCP if there is extravasation of injected contrast from the MPD without filling of the distal MPD [1]. Once the diagnosis of complete MPD disruption has been made, it is often treated by surgery [2], while endotherapy is effective for partial pancreatic ductal disruption [3]. However, we have shown in this case, where both percutaneous and endoscopic contrast injection had demonstrated complete cutoff of the pancreatic duct, that there is still a possibility that the guidewire may cross the site of the disruption and that a stent can be placed to drain the pancreatic juice or PFC. But only if we try!

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* Contributed equally to this work


 
  • References

  • 1 Nadkarni NA, Kotwal V, Sarr MG. et al. Disconnected pancreatic duct syndrome: endoscopic stent or surgeon’s knife?. Pancreas 2015; 44: 16-22
  • 2 Jang JW, Kim MH, Oh D. et al. Factors and outcomes associated with pancreatic duct disruption in patients with acute necrotizing pancreatitis. Pancreatology 2016; 16: 958-965
  • 3 Das R, Papachristou GI, Slivka A. et al. Endotherapy is effective for pancreatic ductal disruption: A dual center experience. Pancreatology 2016; 16: 278-283