What is the most appropriate therapy for a disrupted main pancreatic duct after treated acute necrotizing pancreatitis and endoscopic (scopic) drainage?

From the Guidelines

The most appropriate therapy for a disrupted main pancreatic duct after treated acute necrotizing pancreatitis and endoscopic drainage is endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic duct stent placement. This approach allows for bridging of the disrupted duct, facilitating healing and preventing further leakage of pancreatic enzymes. The procedure typically involves placement of a 5-7 Fr plastic stent across the disruption, which should remain in place for 6-12 months to allow for adequate healing, as suggested by the most recent and highest quality study 1.

Key Considerations

• The use of ERCP with pancreatic duct stent placement is supported by the AGA clinical practice update on the endoscopic approach to recurrent acute and chronic pancreatitis, which recommends prolonged stent therapy for treating symptoms and remodeling main pancreatic duct strictures 1.
• The procedure should be performed by an experienced endoscopist, and patients should receive supportive care including pain management, nutritional support, and monitoring for complications.
• In cases where endoscopic management fails, surgical options may be considered, such as a Roux-en-Y pancreaticojejunostomy or distal pancreatectomy depending on the location of the disruption.
• The rationale behind stenting is to create a low-pressure gradient that favors pancreatic juice flow into the duodenum rather than into the peripancreatic space, thereby allowing the disruption to heal while maintaining drainage of pancreatic secretions through their natural route.

Additional Recommendations

• A multidisciplinary approach, including an endoscopist, interventional radiologist, and surgeons, is recommended for managing complicated cases, as suggested by the consensus guidelines on the optimal management of interventional EUS procedures 1.
• Patients with disconnected pancreatic duct syndrome may benefit from a single-stage surgical transgastric necrosectomy, as suggested by the 2019 WSES guidelines for the management of severe acute pancreatitis 1.
• Percutaneous catheter drainage (PCD) may be considered as a temporizing measure prior to surgery or as an alternative to endoscopic drainage for suboptimal surgical candidates, as suggested by the ACR appropriateness criteria for radiologic management of infected fluid collections 1.

From the Research

Therapy for Disrupted Main Pancreatic Duct

The most appropriate therapy for a disrupted main pancreatic duct after acute necrotizing pancreatitis has been treated and endoscopic (scopic) drainage is a complex issue.

• Endoscopic management has been proven effective in treating patients with complete main pancreatic duct disruption 2.
• A study published in 1995 found that endoscopic treatment, including transpapillary drainage, cystogastrostomy, cystoduodenostomy, or combined procedures, resulted in excellent short-term results with complete cyst resolution and clinical recovery in all but one patient 2.
• Long-term follow-up showed no relapsing clinical symptoms or pseudocyst in 11 patients, with a mean duration of 30.2 months 2.

Comparison of Therapies

• Somatostatin and octreotide have been used to treat pancreatic disorders, but their effectiveness varies 3.
• Somatostatin has been shown to be useful in treating severe acute pancreatitis and preventing complications following ERCP, whereas octreotide has no beneficial effect and may be deleterious in these indications 3.
• A meta-analysis published in 2010 found that somatostatin and high-dose octreotide may prevent post-ERCP pancreatitis, with somatostatin being more effective in certain cases 4.

Combined Therapies

• Combined sinus tract endoscopy and endoscopic retrograde cholangiopancreatography (ERCP) has been used to manage pancreatic necrosis and abscess 5.
• This approach has been shown to be effective in treating pancreatic necrosis or abscess, with a success rate of 67% in one study 5.
• ERCP was required in nine of 13 patients in this study, highlighting the importance of this procedure in managing pancreatic disorders 5.