Disrupted pancreatic duct treated with a combination of endoscopic cystoduodenostomy and pancreatic duct fistualization through a pseudocyst wall using a lumen-apposing metal stent

French reconnection: A conservative pancreato-enteric reconnection for disconnected pancreatic duct syndrome

BACKGROUND/OBJECTIVES

Disconnectedpancreatic duct syndrome (DPDS), a severe complication of acute necrotizing pancreatitis (ANP), may require surgery, usually by distal splenopancreatectomy, thus increasing the risk of diabetes. We describe a new technique reconnecting the distal pancreas to the digestive tract.

METHODS

This technique was proposed after failure of non-surgical treatment and at least 3 months after the onset of ANP in non-diabetic or non-insulin dependent diabetic patients with a distal pancreas of at least 5 cm. The ruptured zone was identified and the distal side was anastomosed to the stomach or the jejunum.

RESULTS

From 2013 to June 2019, 36 patients (median age = 49 years) with DPDS underwent a "French reconnection" procedure, indicated for chronic pain/recurrent pancreatitis (n = 35; 97%), persistent pancreatic fistula (n = 33; 91%), or digestive compression/fistulisation (n = 9; 25%). Median preoperative weight loss was 10 kg (4-27), the median number of hospitalisations per patient was 5(1-8) and 24(67%) patients had received endoscopic/percutaneous treatment. Surgery was performed in median 279(90-2000) days after ANP, laparoscopically in 9(25%) patients. The remnant pancreas (median length = 70 mm; range = 50-130) was anastomosed to the stomach (n = 30) or the jejunum (n = 6). There were 13(36%) postoperative grade B/C pancreatic fistulas and 3(10%) bleedings including one death (mortality = 3%). The median hospital stay was 18 (7-121) days. After a median follow-up of 24 (4-53) months, all pancreatic fistulas had healed and the clinical success rate was 91%. Median BMI increased from 22 to 25 kg/m². In patients with normal pancreatic function, postoperative de novo endocrine and severe exocrine insufficiencies were observed in 4/27 (15%) and 7/22 (32%), respectively.

CONCLUSIONS

The "French reconnection" procedure, as an alternative to distal splenopancreatectomy for the treatment of DPDS, provides good control of symptoms and decreases the risk of pancreatic insufficiency.

Management of the late effects of disconnected pancreatic duct syndrome: A case report

BACKGROUND

There have been few reports about the late effects of disconnected pancreatic duct syndrome (DPDS). Although few reports have described the recurrence interval of pancreatitis, it might be rare for recurrence to occur more than 5 years later. Herein, we describe a case of recurrence in an 81-year-old man after the treatment of walled-off necrosis (WON) with pancreatic transection 7 years ago.

CASE SUMMARY

An 81-year-old man visited our hospital with chief complaints of fever and abdominal pain 7 years after the onset of WON due to severe necrotic pancreatitis. His medical history included an abdominal aortic aneurysm (AAA), hypertension, dyslipidemia, and chronic kidney disease. Computed tomography (CT) scan showed that the pancreatic fluid collection (PFC) had spread to the aorta with inflammation surrounding it, and CT findings suggested that bleeding occurred from the vasodilation due to splenic vein occlusion. First, we attempted to perform transpapillary drainage because of venous dilation around the residual stomach and the PFC. However, pancreatic duct drainage failed because of complete main pancreatic duct disruption. Second, we performed endoscopic ultrasound-guided drainage. After transmural drainage, the inflammation improved and stenting for the AAA was performed successfully. The inflammation was resolved, and he has been free from infection for more than 2 years after the procedure.

CONCLUSION

This case highlights the importance of continued follow-up of patients for recurrence after the treatment of WON with pancreatic transection.

Endoscopic management of complications of acute pancreatitis: an update on the field

INTRODUCTION

Acute pancreatitis is a frequent, nonmalignant gastrointestinal disorder leading to hospital admission. For its severe form and subsequent complications, minimally invasive and endoscopic procedures are being used increasingly, and are subject to rapid technical advances. Areas covered: Based on a systematic literature search in PubMed, medline, and Web-of-Science, we discuss the currently available treatment strategies for endoscopic therapy of pancreatic pseudocysts, walled-off pancreatic necrosis (WON), and disconnected pancreatic duct syndrome (DPDS), and compare the efficacy and safety of plastic and metal stents. A special focus is placed on studies directly comparing different stent types, including lumen-apposing metal stents (LAMS) and clinical outcomes when draining pseudocysts or WONs. The clinical significance and endoscopic treatment options for DPDS are also discussed. Expert commentary: Endoscopic therapy has become the treatment of choice for different types of pancreatic and peripancreatic collections, the majority of which, however, require no intervention. The use of LAMS has facilitated drainage and necrosectomy in patients with WON or pseudocysts. Serious complications remain a problem in spite of high technical and clinical success rates. DPDS is an increasingly recognized problem in the presence of pseudocysts or WONs but evidence for endoscopic stent placement in this situation remains insufficient.