T. K. Maatman1, A. M. Roch1, M. A. Heimberger1, K. A. Lewellen1, R. Cournoyer1, M. G. House1, A. Nakeeb1, E. P. Ceppa1, C. Schmidt1, N. J. Zyromski1 1Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA
Introduction: Disconnected pancreatic duct syndrome (DPDS), complete discontinuity of the pancreatic duct with a viable, but undrained tail, is a relatively common complication following necrotizing pancreatitis (NP). DPDS represents a complex and heterogeneous problem to the clinician; decision-making must consider the presence of sinistral portal hypertension, a variable volume of disconnected pancreatic remnant, and timing relative to definitive management of pancreatic necrosis. Treatment commonly falls to the surgeon; however, limited information is available to guide operative strategy. The aim of this study is to evaluate outcomes after operative management for DPDS.
Methods: An institutional necrotizing pancreatitis database was queried to identify patients with DPDS requiring operative management. When feasible, an internal drainage procedure was performed. In the presence of sinistral portal hypertension, small-volume disconnected pancreatic remnant, or concurrent infected necrosis requiring débridement, distal pancreatectomy with or without splenectomy (DPS/DP) was performed. Descriptive statistics were applied; median (range) values are reported unless otherwise specified.
Results: Among 647 NP patients treated between 2005-2017, DPDS was diagnosed in 289 patients (45%). Operative management was required in 211 patients; 78 patients were managed non-operatively or died of NP prior to DPDS intervention. Median EBL was 250 mL (10-5000). Median follow-up was 19 months (1-158). In 21 patients (10%), pancreatic débridement and external drainage resulted in subsequent fistula closure without need for further intervention. The remaining 185 patients underwent operation as definitive therapy. Internal drainage was performed in 99 and DPS/DP in 86. Time from NP diagnosis to OR was 108 days (5-2439). Morbidity was 53% (table 1). Length of stay was 8 days (3-65). Readmission was required in 49 patients (23%). Post-operative mortality was 1.9%. Death was caused by: ruptured splenic artery pseudoaneurysm (1); intra-operative cardiac event (1); and progressive organ failure following concomitant enterocutaneous fistula (2). Repeat pancreatic intervention was required in 23 patients (11%) at a median of 407 days (119-2947); initial management was internal drainage in 18 and DPS in 5. Salvage pancreatectomy was performed in 10 patients and the remaining 13 patients were managed with endoscopic therapy.
Conclusion: DPDS is a common yet extremely challenging consequence of necrotizing pancreatitis. Patient selection is critical as perioperative morbidity and mortality are serious. Appropriate operation requires complex decision-making, however provides durable long-term therapy in nearly 90% of patients.
