Pancreatic duct (PD) strictures, leaks, and disconnected ducts are important morphologic consequences of inflammatory disease of the pancreas, resulting in abdominal pain, pancreatic ascites, pancreatic pleural effusion, and external pancreatic fistula. Traditionally, these PD complications were treated surgically, but a better understanding of their pathophysiology, along with advancement in endoscopic interventions, has transformed the therapy from morbid surgical interventions to minimally invasive, safe, and effective endoscopic treatment. This review discusses the current diagnostic and management strategies for PD strictures, leaks, and disconnected pancreatic ducts.

Disconnected pancreatic duct syndrome (DPDS) is a pathological condition that causes various symptoms due to the continuous secretion of pancreatic enzymes from the pancreas upstream, which has been separated due to disconnection of the pancreatic duct (DPD) for various reasons.Acute necrotizing pancreatitis includes a certain probability of DPDS appearance, which makes it necessary to provide various treatments for DPDS. Furthermore, DPDS can impact long-term results, such as recurrence and impaired pancreatic function. Although the development of various modalities has contributed to diagnosis and treatment, especially less invasive endoscopic therapy, DPDS is often overlooked, and the diagnosis can be delayed due to the lack of consensus on its definition and classification. This review summarizes the current knowledge and challenges of DPDS and discusses the optimal strategy for its diagnosis and treatment, as well as future perspectives.

Given the lack of established definition, diagnosis, and treatment of DPDS, we conducted a thorough review of the existing literature.

It is emphasized that a standardized definition and classification of DPDS is essential for designing and conducting clinical studies to address current unmet needs in managing patients with DPDS.

Pancreatic fistula is a highly morbid complication of pancreatitis. External pancreatic fistulas result when pancreatic secretions leak externally into the percutaneous drains or external wound (following surgery) due to the communication of the peripancreatic collection with the main pancreatic duct (MPD). Internal pancreatic fistulas include communication of the pancreatic duct (directly or via intervening collection) with the pleura, pericardium, mediastinum, peritoneal cavity, or gastrointestinal tract. Cross-sectional imaging plays an essential role in the management of pancreatic fistulas. With the help of multiplanar imaging, fistulous tracts can be delineated clearly. Thin computed tomography sections and magnetic resonance cholangiopancreatography images may demonstrate the communication between MPD and pancreatic fluid collections or body cavities. Endoscopic retrograde cholangiography (ERCP) is diagnostic as well as therapeutic. In this review, we discuss the imaging diagnosis and management of various types of pancreatic fistulas with the aim to sensitize radiologists to timely diagnosis of this critical complication of pancreatitis.

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.

Disconnected pancreatic duct syndrome (DPDS) is an important and common complication of acute necrotizing pancreatitis. Endoscopic approach has been established as the first-line treatment for pancreatic fluid collections (PFCs) with less invasion and satisfactory outcome. However, the presence of DPDS significantly complicates the management of PFC; besides, there is no standardized treatment for DPDS. The diagnosis of DPDS presents the first step of management, which can be preliminarily established by imaging methods including contrast-enhanced computed tomography, ERCP, magnetic resonance cholangiopancreatography (MRCP), and EUS. Historically, ERCP is considered as the gold standard for the diagnosis of DPDS, and secretin-enhanced MRCP is recommended as an appropriate diagnostic method in existing guidelines. With the development of endoscopic techniques and accessories, the endoscopic approach, mainly including transpapillary and transmural drainage, has been developed as the preferred treatment over percutaneous drainage and surgery for the management of PFC with DPDS. Many studies concerning various endoscopic treatment strategies have been published, especially in the recent 5 years. Nonetheless, existing current literature has reported inconsistent and confusing results. In this article, the latest evidence is summarized to explore the optimal endoscopic management of PFC with DPDS.

For decades, infected or symptomatic pancreatic necrosis was managed by open surgical necrosectomy, an approach that has now been largely supplanted by an array of techniques referred to as the step-up approach.

This review describes the evidence base behind the step-up approach, when to use the different techniques, and their technical basics. The most common treatment strategies are included: percutaneous drainage, video-assisted retroperitoneal debridement, sinus tract endoscopy, endoscopic transgastric necrosectomy, and surgical transgastric necrosectomy. Also included is the evidence base around management of common complications that can occur during step-up management, such as hemorrhage, intestinal fistula, and thrombosis, in addition to associated issues that can arise during step-up management, such as the need for cholecystectomy and disconnected pancreatic duct syndrome.

The treatment strategies highlighted in this review are those most commonly used during step-up management, and this review is designed as a guide to the evidence base underlying these strategies, as surgeons tailor their therapeutic approach to individual patients.

Necrotizing pancreatitis may result in a disrupted or disconnected pancreatic duct (DPD) with the potential for long lasting negative impact on a patient's clinical outcome. There is a lack of detailed data on the full clinical spectrum of DPD which is critical for the development of better diagnostic and treatment strategies.

We performed a long-term post-hoc analysis of a prospectively collected nationwide cohort of 896 patients with necrotizing pancreatitis (2005-2015). The median follow-up after hospital admission was 75 months (P25-P75:41-151). Clinical outcomes of patients with and without DPD were compared using regression analyses, adjusted for potential confounders. Predictive features for DPD were explored.

DPD was confirmed in 243 (27%) of the 896 patients and resulted in worse clinical outcomes during both the patient's initial admission and follow-up. During hospital admission, DPD was associated with an increased rate of new-onset intensive care unit admission (adjusted-OR2.52 [95%-CI 1.62-3.93]), new-onset organ failure (adjusted-OR2.26 [95%-CI 1.45-3.55]), infected necrosis (adjusted-OR4.63 [95%-CI 2.87-7.64]) and pancreatic interventions (adjusted-OR7.55 [95%-CI 4.23-13.96]). During long-term follow-up, DPD increased the risk of pancreatic intervention (adjusted-OR9.71 [95%-CI 5.37-18.30], recurrent pancreatitis (adjusted-OR2.08 [95%-CI 1.32-3.29]), chronic pancreatitis (adjusted-OR2.73 [95%-CI 1.47-5.15]) and endocrine pancreatic insufficiency (adjusted-OR1.63 [95%-CI 1.05-2.53]).Central or subtotal pancreatic necrosis on computed tomography (CT), (OR9.49 [95%-CI 6.31-14.29] and a high levels of serum C-reactive protein (CRP) in the first 48 hours after admission (per 10 points increase, OR1.02 [95%-CI 1.00-1.03] were identified as independent predictors for developing DPD.

At least one of every four patients with necrotizing pancreatitis suffer from DPD which is associated with detrimental, short and long-term interventions and complications. Central and subtotal pancreatic necrosis and high levels of serum CRP in the first 48 hours are independent predictors for DPD.

Disconnected duct syndrome (DDS) is an adverse sequela of acute necrotizing pancreatitis in which there is disruption of the pancreatic duct leading to a failure to deliver pancreatic secretions into the duodenum. Its presentation may range from a persistent external pancreatic fistula to a treatment-resistant pancreatic pseudocyst. The diagnosis is often delayed in the acute setting if there is concurrent necrosis as management is often directed to the associated peripancreatic fluid collection. A combination of imaging modalities may be required to evaluate ductal anatomy. No definitive consensus has been achieved regarding the optimal treatment strategy for DDS, and there is a lack of published level I evidence on the topic. Treatment should be tailored to each individual patient, depending on the anatomy of ductal disruption, the presence of sepsis, the degree of physiological derangement, and the patients' performance status. Patients with DDS represent a specific cohort of patients with complex pancreatic disease that requires the input from a diverse multidisciplinary team to ensure that a good clinical outcome can be achieved.

Disconnected pancreatic duct syndrome (DPDS) is the most common cause of pancreatic fluid collection (PFC) recurrence. While long-term transmural drainage with plastic stents is the preferred endoscopic approach, there is a paucity of literature on patients undergoing initial drainage with lumen-apposing metal stents (LAMS). We describe our experience managing patients with DPDS.

A retrospective review of a prospectively maintained database (November 2015-September 2020) was performed looking at clinical outcomes and overall survival for patients undergoing endoscopic management of PFCs using LAMS. The primary outcome was to assess recurrence-free survival in PFC patients with DPDS managed with or without double pigtail stents (DPS) replacement after LAMS removal.

Of 96 patients with PFCs, 48 with DPDS were included in the study. The median follow-up was 20.1 months. LAMS replacement with DPS was successful in 21/48 (43.8%) patients. Recurrence was seen in 1/21 (5%) patients with DPS replacement and 10/27 (37%) without DPS replacement. In multivariable models, a longer duration of LAMS placement was negatively associated with successful DPS replacement (odds ratio 1.33, 95% confidence interval [CI] 1.11, 1.59, P = 0.0019) and successful LAMS replacement with DPS in patients with DPDS improved recurrence-free survival (hazard ratio 0.09, 95% CI 0.01, 0.83, P = 0.033).

In patients with PFCs and DPDS, early replacement of LAMS with DPS improves the likelihood of successful long-term transmural drainage and decreases recurrences.

The heterogeneous nature of severe acute pancreatitis (SAP) renders decisions related to complications challenging. Central solid collections at the root of the mesentery are difficult to access with traditional techniques. Here we describe a case series of laparoscopic infracolic necrosectomy (ICN) and open or laparoscopic infracolic necrosectomy with Roux-en Y cystjejunostomy (ICN-RYCJ) for the management of complicated SAP.

A retrospective analysis of a prospectively maintained database identified all patients treated with infracolic necrosectomy or drainage of pancreatic collections for complicated SAP between 2012 and 2021 inclusive at a single institution.

Forty patients were identified (median age 53 years)-ICN group 9 patients (median time to intervention-22 days) and ICN-RYCJ group 31 patients (median time to intervention-99 days). Two patients in ICN group underwent interval fistula-tract jejunostomy. Thirty-one patients had laparoscopic surgery and 9 patients underwent an open approach. Four patients required intervention post-operatively. Nineteen patients were discharged from follow-up at two years.

Infracolic approach with selective Roux-en Y cystjejunostomy, as a single or staged intervention, is an effective and safe operative option to add to the armamentarium of the pancreatic surgeon when dealing with complicated SAP not amenable to drainage/debridement by traditional techniques.

Pancreatic fluid collections often develop as a complication of acute pancreatitis but can be seen in a variety of conditions including chronic pancreatitis, trauma, malignancy or post-operatively. It is important to classify a pancreatic fluid collection in order to optimize treatment strategies and management. Most interventions are targeted towards the management of delayed complications of pancreatitis, including pancreatic pseudocysts and walled-off necrosis (WON), which often develop days to weeks after the initial episode of pancreatitis. Surgical, percutaneous, and endoscopic interventions are all possible methods for treatment of pancreatic fluid collections, however endoscopic drainage with endoscopic ultrasound has become first-line. Advances within endoscopic drainage strategies have also led to innovative changes in the specific stents used for treatment, with possible options including double pigtail plastic stents, fully covered self-expanding metal stents and lumen-apposing metal stents (LAMS).

In patients with acute necrotizing pancreatitis (ANP), parenchymal necrosis may involve the pancreatic duct, isolating a segment of the pancreas that remains functional but drains its secretions into the peripancreatic fluid collections, leading to disconnected pancreatic duct syndrome (DPDS). DPDS is an important complication of ANP associated with long-term morbidity and mortality. Unfortunately, this critical entity is under-recognized by radiologists. Endoscopic retrograde cholangiopancreatography (ERCP) is considered the gold standard for diagnosing and treating such patients. However, considering the invasiveness of the ERCP, a noninvasive diagnosis based on radiological tests is desirable. Radiological literature concerning the diagnosis of DPDS is scarce, and there is substantial ambiguity regarding the radiological definitions of DPDS.

Considering the scarcity of published literature regarding the reliable radiologic diagnosis of DPDS, we performed a thorough review of the existing literature to identify definitions and features of this entity on computed tomography (CT) and magnetic resonance imaging (MRI).

Existing literature regarding radiologic diagnosis of DPDS was reviewed and analyzed and a comprehensive imaging definition of DPDS was proposed.

Disconnected pancreatic duct syndrome (DPDS) is a recognized complication of necrotizing pancreatitis (NP). Manifestations include recurrent peripancreatic fluid collections (R-PFC) and pancreatocutaneous fistulae (PC-Fistulae). Pancreatitis of the disconnected pancreatic segment (DPDS-P) and its relationship to new-onset diabetes after pancreatitis (NODAP) are not well characterized.

We performed a retrospective cohort study of consecutive patients with NP admitted to University of California, San Francisco from January 2011 to June 2019. A diagnosis of a disconnected pancreatic duct (PD) was confirmed using computed tomography and magnetic resonance cholangiopancreatography/endoscopic retrograde cholangiopancreatography. DPDS was defined as a disconnected PD presenting with R-PFC, PC-Fistulae, or DPDS-P. The primary outcome was NODAP, defined as diabetes mellitus (DM) occurring >3 months after NP. Cox proportional hazards regression was used to evaluate the relationship between DPDS and NODAP.

Of 171 patients with NP in this study, the mean clinical follow-up was 46 ± 18 months and the imaging follow-up was 38 ± 20 months. Twenty-seven patients (16%) developed DPDS-P at a median of 28 months. New-onset DM occurred in 54 of the 148 patients (36%), with 22% developing DM within 3 months of NP and 14% developing NODAP at a median of 31 months after AP. DPDS-P was associated with NODAP when compared with non-DPDS patients (adjusted hazard ratio 5.63 95% confidence interval: 1.69-18.74, P = 0.005) while R-PFCs and PC-Fistulae were not.

DPDS and NODAP occurred in 28% and 14% of the patients, respectively. Pancreatitis of the disconnected pancreas occurred in 16% of the patients and was associated with higher rates of NODAP when compared with patients with other manifestations of DPDS and patients without DPDS.

The review is devoted to diagnosis and treatment of disconnected pancreatic duct syndrome (DPDS) in patients with acute pancreatitis. Data on terminology, indications and options for endoscopic transluminal interventions are presented in detail. The results of numerous studies evaluating clinical efficacy of various endoscopic and open surgical procedures are analyzed. Available data confirm advisability of staged treatment of DPDS with primary endoscopic drainage of pancreatic fluid accumulations in specialized centers.

Imaging plays a major role to differentiate interstitial edematous from necrotic pancreatitis and to describe relevant local complications for proper patient management and decision-making in acute pancreatitis.

The revised Atlanta classification 2012 of acute pancreatitis divides patients into mild, moderately severe and severe groups. Computed tomography (CT) and magnetic resonance imaging (MRI) are well established for diagnosis and follow-up of acute pancreatitis and its complications METHODOLOGICAL INNOVATIONS AND ASSESSMENT: Based on the revised Atlanta classification, CT and MRI allow for adequate categorization of interstitial edematous and necrotic pancreatitis. Imaging and standardized reporting nomenclature enable confident differentiation of early and late complications in acute pancreatitis.

The aim of this review article is to present an image-rich overview of different morphologic characteristics of acute pancreatitis and associated local complications by CT or MRI using case examples.

Indwelling plastic endoprosthesis in patients with disconnected pancreatic duct syndrome (DPDS) reduces the risk of pancreatic fluid collection (PFC) recurrence. Although lumen-apposing metal stents (LAMS) are used with increasing frequency for PFC drainage, they require timely removal and little is known about their effects in patients with DPDS and recurrence of PFC.

We performed a prospective study of patients who underwent endoscopic ultrasound-guided drainage of PFC using LAMS and were found to have DPDS. After resolution of PFC, LAMS were replaced with double-pigtail plastic stents. The primary outcome was to compare PFC recurrence between patients with DPDS who did vs did not receive replacements with plastic stents after removal of the LAMS.

Of 188 PFC patients treated with LAMS, 94 had DPDS, 71 had intact pancreatic ducts, and duct patency was unknown in 23. In patients with DPDS, replacement of LAMS with plastic stents was successful in 70 patients (74.5%) and technically unsuccessful in 24 patients (25.5%). At a median follow up of 183 days (interquartile range, 179-188 days), although none of the patients with an intact duct had a recurrence of PFC, 7 of the 94 patients with DPDS had recurrence of PFC (7.4%) (P = .020). PFC recurred in 1 of 70 patients with DPDS in whom replacement of LAMS with plastic stent was successful (1.4%) and in 6 of 24 patients with unsuccessful stent replacement (25.0%) (P = .001).

In treatment of PFCs with LAMS in patients with DPDS, it is important to replace the LAMS with indwelling plastic stents to minimize PFC recurrence and reduce morbidity. Clinicaltrials.gov no: NCT02422095.

Severe pancreatitis may result in a disrupted pancreatic duct, which is associated with a complicated clinical course. Diagnosis of a disrupted pancreatic duct is not standardized in clinical practice or international guidelines. We performed a systematic review of the literature on imaging modalities for diagnosing a disrupted pancreatic duct in patients with acute pancreatitis.

A systematic search was performed in PubMed, Embase and Cochrane library databases to identify all studies evaluating diagnostic modalities for the diagnosis of a disrupted pancreatic duct in acute pancreatitis. All data regarding diagnostic accuracy were extracted.

We included 8 studies, evaluating five different diagnostic modalities in 142 patients with severe acute pancreatitis. Study quality was assessed, with proportionally divided high and low risk of bias and low applicability concerns in 75% of the studies. A sensitivity of 100% was reported for endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. The sensitivity of magnetic resonance cholangiopancreatography with or without secretin was 83%. A sensitivity of 92% was demonstrated for a combined cohort of secretin-magnetic resonance cholangiopancreatography and magnetic resonance cholangiopancreatography. A sensitivity of 100% and specificity of 50% was found for amylase measurements in drain fluid compared with ERCP.

This review suggests that various diagnostic modalities are accurate in diagnosing a disrupted pancreatic duct in patients with acute pancreatitis. Amylase measurement in drain fluid should be standardized. Given the invasive nature of other modalities, secretin-magnetic resonance cholangiopancreatography or magnetic resonance cholangiopancreatography would be recommended as first diagnostic modality. Further prospective studies, however, are needed.

Persistent pancreatic leakage (PL) due to disconnected pancreatic duct syndrome (DPDS) is associated with severe morbidity and mortality and it usually treated with internal drainage. However, in cases without localized fistula formation, internal drainage is challenging to perform. We report an original one-stage surgical approach for nonlocalized persistent PL, namely, the "intentional internal drainage tube method".

A 49-year-old woman whose main pancreatic duct was penetrated during endoscopic retrograde cholangiopancreatography experienced severe PL. Peritoneal lavage and a second operation involving central pancreatectomy failed to relieve the symptoms, and nonlocalized PL persisted due to DPDS. Although we attempted a radical resection of the pancreatic remnants as a third strategy, the highly inflamed tissue and massive bleeding prevented the completion of the procedure. We sutured the pancreatic head margin and performed a pancreaticojejunostomy to the distal margin. Because these two cut margins could possibly be the source of the persistent PL, we created a hole at the Roux-en-Y jejunal limb, and a silicone drainage tube was inserted into the peritoneal space via this hole. Postoperatively, we continuously suctioned the intentional internal drainage tube, and the residual PL cavity gradually diminished. Even after removal of the tube, the residual PL drained internally into the jejunum through this hole.

We present this intentional internal drainage tube method as a novel alternative approach for the management of nonlocalized PL consequential of DPDS. Due to the simplicity and minimally invasive nature of this method, we propose this technique may also be used to treat various types of nonlocalized persistent PL or be used prophylactically for central pancreatectomy.

Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aimed to review the definitions, clinical presentation, intervention, and outcomes for DPDS.

The PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites.

Thirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.3%, 936/982), followed by chronic pancreatitis (3.1%, 30/982). DPDS commonly presented with PFC (83.2%, 948/1140) and EPF (13.4%, 153/1140). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI 81.0-95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7-77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6-90.5) and 87.4% (95%-CI 81.2-91.8), respectively (P = 0.389).

Endoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research.

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.

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.

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.

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.

Disconnected Pancreatic Duct Syndrome (DPDS) is an important but often overlooked complication of acute necrotising pancreatitis (ANP) that occurs due to necrosis of the main pancreatic duct (PD). This segmental necrosis leads on to disconnection between the viable upstream pancreatic parenchyma and the duodenum. The disconnected and functional segment of pancreas continues to secrete pancreatic juice that is not drained into the gastrointestinal tract and lead on to recurrent pancreatic fluid collections (PFC), refractory external pancreatic flstulae and chronic abdominal pain/recurrent pancreatitis. Because of lack of awareness of this important complication of ANP, the diagnosis of DPDS is usually delayed. The delay in diagnosis increases the morbidity of the disease as well as increase the cost of treatment and duration of hospital stay. Surgery has remained the cornerstone for management of patients with DPDS. The conventional surgical approaches have been either resection or internal drainage procedures. Surgery for DPDS in the setting of ANP is often difficult due to presence of local inflammation and extensive venous collaterals in the operative field due to splenic vein thrombosis and therefore is associated with significant morbidity. Advancement in therapeutic endoscopy, especially advent of therapeutic endoscopic ultrasound has opened an exciting new field of minimally invasive therapeutic options for management of DPDS. The present review discusses the current understanding of the clinical manifestations, imaging features and management strategies in patients with DPDS.

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition.

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis. BEST PRACTICE ADVICE 1: Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center. BEST PRACTICE ADVICE 2: Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended. BEST PRACTICE ADVICE 3: When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography-guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases. BEST PRACTICE ADVICE 4: In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated. BEST PRACTICE ADVICE 5: Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. BEST PRACTICE ADVICE 6: Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication. BEST PRACTICE ADVICE 7: Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula. BEST PRACTICE ADVICE 8: Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden. BEST PRACTICE ADVICE 9: Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis. BEST PRACTICE ADVICE 10: The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup. BEST PRACTICE ADVICE 11: Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity. BEST PRACTICE ADVICE 12: Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources. BEST PRACTICE ADVICE 13: Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures. BEST PRACTICE ADVICE 14: For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting. BEST PRACTICE ADVICE 15: A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise.

Pancreatic fluid collections in early phase of illness <4 weeks after onset of acute pancreatitis (AP) are usually treated with percutaneous drainage (PCD). There is a paucity of data comparing early (<4 weeks) endoscopic transluminal drainage (ETD) with PCD in patients with symptomatic pancreatic necrosis (PN). The objective of this study is to compare the safety and efficacy of early ETD with PCD in patients with symptomatic PN.

Retrospective analysis of database of patients with symptomatic PN treated early (<4 weeks of onset of AP) with either ETD (encapsulated wall on EUS) or PCD.

Twenty-three patients (19 M; mean age: 36.1 years) were treated with ETD and 41 patients (29 M; mean age: 39.6 years) were treated with PCD, respectively. ETD and PCD were done 24.2 ± 2.3 and 24.2 ± 2.0 days after onset of AP, respectively (P = 0.84). In the ETD group, 35% of patients were treated with self-expanding metallic stents and 48% of patients required direct endoscopic necrosectomy. In the PCD group, 74% of patients were treated with multiple catheters and 91% of patients with either saline or streptokinase irrigation. As compared to the ETD group, patients in the PCD group took longer time for resolution (61.9 ± 22.9 days vs. 30.9 ± 5.6 days; P < 0.00001), increased need for surgery (30% vs. 4%; P = 0.01), and frequency of formation of external pancreatic fistula (EPF) (22% vs. nil; P = 0.02).

ETD of PN in early phase of illness is associated with a shorter duration for resolution and infrequent need of salvage surgery compared to PCD. EPF formation is a significant adverse event with PCD.

Acute pancreatitis is classically characterized by acute chemical inflammation of the pancreatic gland itself, peripancreatic tissues, and even remote organs. The newly revised Atlanta Classification 2012 redefined the patterns of pancreatic necrosis and local complications in acute pancreatitis. The Atlanta Classification's novelty was in emphasizing that extrapancreatic fat necrosis, which leads to walled-off necrosis, is associated with poor prognosis. Conversely, the free fluid liquid was considered to be less related to complications. The Atlanta's classification's main weakness is that it is mainly computed tomography (CT) based, as contrast-enhanced CT is the predominant imaging technique used for evaluating a wide range of pathological processes of acute pancreatitis. However, some local complications are difficult to distinguish accurately on CT. Recent advances, including significantly better soft-tissue contrast, favor multiparametric magnetic resonance imaging (mpMRI) for a more comprehensive assessment of acute pancreatitis pathology, particularly for small necrotic/fat debris within a collection. In addition, the MRI severity index (MRSI), which combines Balthazar's grade points and points of the extent of pancreatic necrosis, has been proven to be crucial for the initial evaluation, staging, and prognosis of acute pancreatitis. Other innovations, such as the recognition of important MRI features in acute pancreatitis and the utilization of newer, more effective terminology for imaging reporting assistance in the differentiation of the common local complications following this disease, have improved the treatment for acute pancreatitis. In this paper, with reference to the 2012 revised Atlanta classification, we review the strengths and limitations of MRI for identifying acute pancreatitis, the MRI findings of a spectrum of pathological entities, and the important local complications secondary to acute pancreatitis.

Disconnected pancreatic duct syndrome (DPDS) is common after necrotizing pancreatitis (NP). Surgical management may be by internal drainage or left (distal) pancreatectomy. Therapeutic decision-making must consider sinistral portal hypertension, parenchymal volume of disconnected pancreas, and timing relative to definitive management of pancreatic necrosis. The aim of this study is to evaluate outcomes after operative management for DPDS.

All patients with NP undergoing an operation for DPDS were included in the study (2005-2017). Perioperative outcomes and long-term durability were evaluated.

Among 647 patients with NP, 299 (46%) had DPDS. Operative management was required in 202/299 (68%) patients with DPDS. Median follow-up was 30 mo (2-165). Definitive operative therapy included internal drainage (n = 111) or resection (n = 91). Time from NP diagnosis to operation was 126 d (20 d to 81 mo). Overall morbidity was 46%. Postoperative length of stay was 7 d (2-97). Readmission was required in 39 patients (19%). Mortality was 2%. Repeat pancreatic intervention was required in 23 patients (11%) at a median of 15 mo (1-98). Repeat pancreatectomy was performed in nine patients and the remaining 14 patients were managed with endoscopic therapy.

DPDS is a common and challenging consequence of NP. Appropriate operation is durable in nearly 90% of patients.

Necrotizing pancreatitis may lead to loss of integrity of the pancreatic duct, resulting in leakage of pancreatic fluid. Pancreatic duct disruption or disconnection is associated with a prolonged disease course and particular complications. Since a standard treatment for this condition is currently lacking, we performed a systematic review of the literature to compare outcomes of various treatment strategies.

A systematic review was performed according to the PRISMA guidelines in the PubMed, EMBASE and Cochrane databases. Included were articles considering the treatment of patients with disrupted or disconnected pancreatic duct resulting from acute necrotizing pancreatitis.

Overall, 21 observational cohort studies were included comprising a total of 583 relevant patients. The most frequently used treatment strategies included endoscopic transpapillary drainage, endoscopic transluminal drainage, surgical drainage or resection, or combined procedures. Pooled analysis showed success rates of 81% (95%-CI: 60-92%) for transpapillary and 92% (95%-CI: 77-98%) for transluminal drainage, 80% (95%-CI: 67-89%) for distal pancreatectomy and 84% (95%-CI: 73-91%) for cyst-jejunostomy. Success rates did not differ between surgical procedures (cyst-jejunostomy and distal pancreatectomy (risk ratio = 1.06, p = .26)) but distal pancreatectomy was associated with a higher incidence of endocrine pancreatic insufficiency (risk ratio = 3.06, p = .01). The success rate of conservative treatment is unknown.

Different treatment strategies for pancreatic duct disruption and duct disconnection after necrotizing pancreatitis show high success rates but various sources of bias in the available studies are likely. High-quality prospective, studies, including unselected patients, are needed to establish the most effective treatment in specific subgroups of patients, including timing of treatment and long-term follow-up.

Many techniques have been developed to prevent postoperative pancreatic fistula (POPF) after distal pancreatectomy, but POPF rates remain high. The aim of our study was to analyze POPF occurrence after closure of the pancreatic remnant by different operative techniques.

Between 2006 and 2017, 284 patients underwent distal pancreatectomy in our institution. For subgroup analysis the patients were divided into hand-sewn (n = 201) and stapler closure (n = 52) groups. The hand-sewn closure was performed in three different ways (fishmouth-technique, n = 27; interrupted transpancreatic U-suture technique, n = 77; common interrupted suture, n = 97). All other techniques were summarized in a separate group (n = 31). Results were gained by analysis of our prospective pancreatic database.

The median age was 63 (range 23-88) years. 74 of 284 patients (26%) were operated with spleen preservation (similar rates in subgroups). ASA-classes, median BMI as well as frequencies of malignant diseases, chronic pancreatitis, alcohol and nicotine abuse were also comparable in the subgroups. Neither the rates of overall POPF (fishmouth-technique 30%, common interrupted suture 40%, stapler closure 33% and interrupted U-suture 38%) nor the rates of POPF grades B and C showed significant differences in the subgroups. However is shown to be associated with pancreatic function and parenchymal texture.

In our experience the technique of pancreatic stump closure after distal resection did not influence postoperative pancreatic fistula rate. As a consequence patient specific reasons rather than surgical techniques may be responsible for POPF formation after distal pancreatectomy.

Endoscopic interventions play an important role in the modern management of pancreatic fluid collections. Successful management of pancreatitis is dependent on proper classification of the disease and its local complications. The 2012 revised Atlanta classification divides acute pancreatitis into subtypes of necrotizing pancreatitis and interstitial edematous pancreatitis (IEP) on the basis of the radiologic presence or absence of necrosis, respectively. Local complications of IEP include acute pancreatic fluid collections and pseudocysts, which contain fluid only and are differentiated by the time elapsed since the onset of symptoms. Local complications of necrotizing pancreatitis include acute necrotic collections and walled-off necrosis, which contain nonliquefied necrotic debris and are differentiated by the time elapsed since the onset of symptoms. Endoscopic techniques are used to treat local complications of pancreatitis, often in a step-up approach, by which less invasive techniques are preferred initially with potential subsequent use of more invasive procedures, dependent on the patient's clinical response and collection evolution. Common interventions performed by the advanced endoscopist include endoscopic transmural drainage and endoscopic transmural necrosectomy. However, some collections require a multimodal approach with adjunctive placement of percutaneous drainage catheters or the use of videoscopic-assisted retroperitoneal débridement. Additional endoscopic interventions may be required in the setting of pancreatic or biliary duct stones or strictures. Common complications of endoscopic intervention in the setting of pancreatitis include bleeding, infection, perforation, and stent migration. This article reviews the classification of acute pancreatitis, familiarizes radiologists with the common endoscopic techniques used in its management, and improves identification of the clinically relevant imaging findings and procedural complications related to endoscopic interventions in pancreatitis. ^©RSNA, 2018.

Severe necrotizing pancreatitis may result in midbody necrosis and ductal disruption leaving an isolated pancreatic tail. The purpose of this study was to characterize outcomes among patients with an isolated tail remnant who underwent transgastric drainage or necrosectomy (endoscopic or surgical) and determine the need for subsequent operative management.

Patients with necrotizing pancreatitis and retrogastric walled-off collections treated by surgical transgastric necrosectomy or endoscopic cystgastrostomy ± necrosectomy between 2009 and 2017 were identified by a retrospective chart review. All available preprocedure and postprocedure imaging was reviewed for evidence of isolated distal pancreatic tail remnants.

Seventy-four patients were included (40 surgical and 34 endoscopic). All the patients in the surgical group underwent laparoscopic transgastric necrosectomy; the endoscopic group consisted of 26 patients for pseudocyst drainage and eight patients for necrosectomy. A disconnected pancreatic tail was identified in 22 (29%) patients (13 laparoscopic and nine endoscopic). After the creation of the "cystgastrostomy," there were no external fistulas despite the viable tail. Of the 22 patients, four patients developed symptoms at a median of 23 months (two, recurrent episodic pancreatitis; two, intractable pain). Two patients (both initially in endoscopic group) ultimately required distal pancreatectomy and splenectomy at 24 and 6 months after index procedure.

Patients with a walled-off retrogastric collection and an isolated viable tail are effectively managed by a transgastric approach. Despite this seemingly "unstable anatomy," the creation of an internal fistula via surgical or endoscopic "cystgastrostomy" avoids external fistulas/drains and the short-term necessity of surgical distal pancreatectomy. A very small subset requires intervention for late symptoms.

Disconnected pancreatic duct syndrome (DPDS) is defined as the complete disruption of the main pancreatic duct, the result are peripancreatic fluid collections or pancreatic leaks. The aim of this study was to report the results of derivative endoscopic treatment of DPDS in a long-term follow-up period.

We performed a retrospective analysis of prospectively collected data. Endoscopic treatment consisted of transmural drainage with 2 double pigtail plastic stents (7 F and 4 cm) deployed under endoscopic ultrasound guidance.

In total, 21 patients were included in our study. There were 15 (71%) men and the median age was 36 years (range, 23 to 86 y). The principal etiology of DPDS was acute pancreatitis. A total of 20 (95.2%) patients were diagnosed with DPDS by endoscopic pancreatography and only 1 (4.8%) patient by magnetic resonance cholangiopancreatography (MRCP). The median follow-up time was 28 months (range, 7 to 76 mo). Technique success was 100% and initial clinical success was 80.9% (17/21). Three (17.6%) of these patients required a new endoscopic procedure with success in all cases. During follow-up, 11 (52%) patients developed diabetes mellitus and 3 patients (14%) developed exocrine pancreatic insufficiency. There were 5 (15%) patients with complications.

According to our data, endoscopic treatment with the placement of a permanent indwelling transmural stents is a useful and safe tool for the treatment of DPDS.

Pain secondary to chronic pancreatitis is a difficult clinical problem to manage. Many patients are treated medically or undergo endoscopic therapy and surgical intervention is often reserved for those who have failed to gain adequate pain relief from a more conservative approach.

There have been a number of advances in the operative management of chronic pancreatitis over the last few decades and current therapies include drainage procedures (pancreaticojejunostomy, etc.), resection (pancreticoduodenectomy, etc.) and combined drainage/resection procedures (Frey procedure, etc.). Additionally, many centers currently perform total pancreatectomy with islet autotransplantation, in addition to minimally invasive options that are intended to tailor therapy to individual patients.

Operative management of chronic pancreatitis often improves quality of life, and is associated with low rates of morbidity and mortality. The decision as to which procedure is optimal for each patient should be based on a combination of pathologic changes, prior interventions, and individual surgeon and center experience.

A disconnected distal pancreas (DDP) remnant is a morbid sequela of necrotizing pancreatitis. Definitive surgical management can be accomplished by either fistulojejunostomy (FJ) or distal pancreatectomy (DP). It is unclear which operative approach is superior with regard to short- and long-term outcomes.

Between 2002 and 2014, patients undergoing either FJ or DP for DDP were retrospectively identified at a center specializing in pancreatic diseases. Patient demographics, perioperative, and postoperative variables were evaluated.

Forty-two patients with DDP secondary to necrotizing pancreatitis underwent either a FJ (n = 21) or DP (n = 21). Between the two cohorts, there were no significant differences in overall lengths of stay, pancreatic leak rates, or readmission rates (all p > 0.05). DP was associated with higher estimated blood loss, increased transfusion requirements, and worsening endocrine function (all p < 0.05). At a median follow-up of 18 months, four patients that underwent a FJ developed a recurrent fluid collection requiring re-intervention. Overall, FJ was successful in 80% of patients as compared to a 95% success rate for DP (p = 0.15).

Although DP was associated with higher intraoperative blood loss, increased transfusion requirements, and worsening of preoperative diabetes, this procedure provides superior long-term resolution of a DDP when compared to FJ.

Management of disconnected pancreatic duct syndrome is complex and is increasingly approached using emerging endoscopic techniques. Herein, we present a case of recurrent pancreatitis in an elderly woman complicated by pseudocyst formation and complete pancreatic duct disruption. Her condition was treated with a novel combination of transpapillary stenting and cystduodenostomy in which a pancreatic duct stent was placed into an opening in the pseudocyst wall through a lumen-apposing metal stent. This allowed for effective drainage into the gastrointestinal tract and resolution of duct disruption. Post-procedure, the patient has had recovery of nutritional status and no further recurrence of pancreatic fluid collection. Endoscopic approaches to complete pancreatic duct disruption represent a viable and less invasive alternative to surgical management in selected cases.

Disconnected pancreatic duct syndrome is a circumferential interruption of the pancreatic duct. It usually occurs secondary to pancreatitis and carries significant diagnostic and management challenges. We present a case of disconnected pancreatic duct syndrome that represented a diagnostic and management dilemma for both medical and surgical teams. The aim of this article is to share a successful management experience of disconnected pancreatic duct syndrome with other physicians and to perform a brief but focused literature review on this challenging condition.