Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis

Murage, Kariuki P.; Ball, Chad G.; Zyromski, Nicholas J.; Nakeeb, Attila; Ocampo, Carlos; Sandrasegaran, Kumaresan; Howard, Thomas J.

doi:10.1016/j.surg.2010.07.039

Cited by 57 publications

(54 citation statements)

References 24 publications

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“…Historically, DDS has required surgical excision of the isolated tail segment of the pancreas. However, several endoscopic and interventional alternatives have been developed, although treatment success remains variable …”

Section: Disconnected Duct Syndromementioning

confidence: 99%

“…However, several endoscopic and interventional alternatives have been developed, although treatment success remains variable. 59 Endoscopic management of DDS has been described in several series and reviews. 2,38,52,58,60,61 This method employs transmural drainage of fluid collections as described in the previous section for treatment of pseudocysts; however, the transmural stents are left in place indefinitely.…”

Section: Disconnected Duct Syndromementioning

confidence: 99%

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Management of pancreatic ductal leaks and fistulae

Larsen

Kozarek

2014

J of Gastro and Hepatol

106

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Pancreatic duct leaks can occur as a result of both acute and chronic pancreatitis or in the setting of pancreatic trauma. Manifestations of leaks include pseudocysts, pancreatic ascites, high amylase pleural effusions, disconnected duct syndrome, and internal and external pancreatic fistulas. Patient presentations are highly variable and range from asymptomatic pancreatic cysts to patients with severe abdominal pain and sepsis from infected fluid collections. The diagnosis can often be made by high-quality cross-sectional imaging or during endoscopic retrograde cholangiopancreatography (ERCP). Because of their complexity, pancreatic leak patients are best managed by a multidisciplinary team comprised of therapeutic endoscopists, interventional radiologists, and surgeons in the field of pancreatic interventions. Minor leaks will often resolve with conservative management while severe leaks will frequently require interventions. Endoscopic treatments for pancreatic duct leaks have replaced surgical interventions in many situations. Interventional radiologists also have the ability to offer therapeutic interventions for many leak patients. The mainstay of endotherapy for pancreatic leaks is transpapillary pancreatic duct stenting with a stent that bridges the leak if possible, but varies based on the manifestation and clinical presentation. Fluid collections that result from leaks, such as pseudocysts, can often be treated by endoscopic transluminal drainage with or without endoscopic ultrasound or by percutaneous drainage. Endoscopic interventions have been shown to be effective and have an acceptable complication rate.

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Section: Disconnected Duct Syndromementioning

confidence: 99%

Section: Disconnected Duct Syndromementioning

confidence: 99%

Management of pancreatic ductal leaks and fistulae

Larsen

Kozarek

2014

J of Gastro and Hepatol

106

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“…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.…”

Section: Discussionmentioning

confidence: 99%

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

Gámez-del-Castillo¹,

Garcés-Albir²,

Fernández-Moreno³

et al. 2016

Rev Esp Enferm Dig

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Disconnected pancreatic duct syndrome: complete pancreas transection secondary to acute pancreatitisKey words: Pancreas. Pancreatitis. Disconnected pancreatic duct syndrome. Dear Editor,Disconnected pancreatic duct syndrome (DPDS) is defined by a complete discontinuity of the pancreatic duct, such that a viable side of the pancreas remains isolated from the gastrointestinal tract. The most frequent causes are acute pancreatitis and pancreatic trauma, with a 10-30% incidence in acute pancreatitis (1,2). However, there is a lack of reliable epidemiologic data. This pancreatic disruption is infrequent in clinical practice and its diagnostic and therapeutic management are controversial. We present an extreme case of disconnected pancreatic duct syndrome with complete duct disruption and pancreatic transection following acute pancreatitis, as well as the diagnostic and therapeutic processes carried out. Case reportA 56-year-old female with a medical history of dyslipidemia and hypothyroidism was admitted to a regional hospital for severe acute idiopathic pancreatitis. During hospitalization she developed a large pseudocyst in the pancreatic neck region. The patient underwent 3 unsuccessful attempts to cannulate the pancreatic duct by endoscopic retrograde cholangiopancreatography (ERCP) as it was not possible to identify the pancreatic duct distal to the pseudocyst. Percutaneous drainage was then indicated, which resolved the pseudocyst but led to an external pancreatic fistula. The patient was discharged after conservative management of the fistula for three months, and referred to our hospital for reconsideration of the therapeutic management.By that time, the patient was asymptomatic and the pancreatic fistula remained closed. However, she presented an exocrine pancreatic insufficiency treated with pancreatic enzyme replacement therapy. The patient underwent conservative management and close follow-up with physical examination and radiologic imaging with CT-scan or MRI alternatively with endoscopic ultrasound every 6 months.After two years of uneventful follow-up the patient developed progressive abdominal pain. Radiologic imaging demonstrated a marked dilation of distal pancreatic duct ( Fig. 1 A and B). This finding was confirmed by endoscopic ultrasound suggesting an intraductal papillary mucinous neoplasm (IPMN).Due to the above findings, the patient underwent surgery. Intraoperatively, a complete transection throughout the pancreas parenchyma with duct disruption at the neck was found, with a space between both pancreatic edges of about 2 cm, where portomesenteric axis was located. Distal pancreatectomy involving isolated pancreatic side and splenectomy was carried out.The patient evolved without complications after surgery and was discharged on the 7 th post-operative day. Histopathologic examination revealed chronic pancreatitis without any characteristic suggestive of IPMN. DiscussionDisconnected pancreatic duct syndrome (DPDS) is characterized by a discontinuity of the pancreatic duct and consequent lack ...

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“…A common occurrence in necrotizing pancreatitis is necrosis of the pancreatic neck parenchyma leaving viable upstream tail and downstream head with disconnection of the main pancreatic duct, the so called disconnected left pancreatic remnant. External drainage in this situation results in a persistent pancreatic fistula that frequently requires reoperative intervention for definitively treatment [23]. Currently accepted practice is to wait at least 4 weeks from the initial insult of pancreatitis prior to débridement; this time period allows consolidation and maturation of the (peri) pancreatic collections and facilitates a single débridement.…”

Section: Patient Selectionmentioning

confidence: 99%

Laparoscopic Transgastric Pancreatic Débridement

Zyromski

2013

Curr Surg Rep

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Open operative debridement has been the traditional approach to patients with pancreatic necrosis. Recently, improved understanding of the disease natural history coupled with significant advances in minimally invasive interventional techniques (both endoscopic and laparoscopic) have led clinicians to apply these minimally invasive interventions to pancreatic debridement. This report details one such minimally invasive approachlaparoscopic transgastric pancreatic necrosectomy. A thorough understanding of this complex and heterogeneous disease process is necessary to select patients properly for the most appropriate therapeutic approach.

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Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis

Cited by 57 publications

References 24 publications

Management of pancreatic ductal leaks and fistulae

Management of pancreatic ductal leaks and fistulae

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

Laparoscopic Transgastric Pancreatic Débridement

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