Disconnection of the Pancreatic Duct: An Important But Overlooked Complication of Severe Acute Pancreatitis

Abstract

In patients with severe acute pancreatitis, the percentage of necrosis of pancreatic glandular parenchyma is an important predictor of prognosis. However, little attention has been paid to necrosis of ductal epithelium, which may result in disconnection of the main pancreatic duct. In pancreatic duct disconnection, a viable segment of the pancreatic body or tail is isolated from the gastrointestinal tract; the result is a persistent end fistula, that is, an uncontrolled leak of pancreatic secretions into peripancreatic spaces without communication to the gastrointestinal tract. The authors present their experience with clinical and radiologic follow-up of 85 patients with necrotic pancreatitis who either did (n = 46) or did not (n = 39) have pancreatic duct disconnection at surgery. Confident preoperative diagnosis of a disconnected duct requires both imaging tests (computed tomography or magnetic resonance imaging) and pancreatography. However, not all peripancreatic collections signify ductal disconnection, and imaging has poor accuracy in differentiation between pancreatic and peripancreatic necrosis. Early recognition of disconnected pancreatic duct obviates unnecessary and potentially harmful drainage procedures.

Magnetic resonance imaging for acute pancreatitis

“…Patients with pancreatic necrosis are routinely monitored in the intensive care unit because the increased mortality has been shown to correlate directly with the presence and degree of pancreatic necrosis [4] . Thus, the early detection of pancreatic necrosis is a prognostic indicator in these patients [5] . However, recognition of pancreatic necrosis by means of clinical examination is unreliable, therefore, the importance of diagnostic imaging for that purpose is clinically emphasized.…”

“…Alcoholism and choledocholithiasis are the most common etiological factors for this disease [2][3][4][5][6] . The clinical variety of mild acute pancreatitis (70%-80% of patients), also called edematous interstitial pancreatitis, exhibits a self-limiting disease with no or minimal organ dysfunction, without complications, and with a favorable prognosis [1] .…”

“…Imaging for acute pancreatitis has a significant role in confirming the diagnosis of this disease, which helps to detect pancreatic necrosis and diagnose local complications [9] . Furthermore, imaging is useful in the early assessment of disease severity [5,10,11] .bladder and/or common duct stones in acute pancreatitis. However, visualization of the pancreas is often disturbed by overlying gastrointestinal gas, which is an important limitation for US applications in this disease [8] .…”

Disconnected pancreatic duct syndrome: Complete pancreas transection secondary to acute pancreatitis

“…The criteria for diagnosing DPDS include necrosis of at least 2 cm in the neck or body of the pancreas, the existence of viable distal pancreatic tissue from necrosis region and the extravasation of contrast material injected into the main pancreatic duct at pancreatography obtained by ERCP (5).…”

“…Although there is a lack of clinical and epidemiological data and therapeutic algorithms are not clearly defined, the accumulated experience of high-volume hospitals has enabled the following conclusions (2,3,(5)(6)(7): the diagnosis must be suspected after severe acute necrotising pancreatitis, primarily when collections or necrosis involve central areas of the pancreas; the diagnosis is based on CT, MRI and ERCP findings; if DPDS is suspected by radiologic imaging, percutaneous drainage must be avoided due to the risk of external pancreatic fistula development which would be difficult to resolve. Endoscopic techniques are better options if drainage or necrosectomy are needed.…”