A modified approach for EOS-guided management of Disconnected Pancreatic Doct Syndrome These are our disclosures. Disconnected Pancreatic Doct Syndrome refers to disruption of the integrity of the main pancreatic duct, often occurring as a sequelae of necrotizing pancreatitis. This results in leakage of pancreatic secretions, putting the patient at risk of recurrent acute pancreatitis and other complications. ERCP-based bridging of the pancreatic duct is often not feasible due to complete ductal disruption. EOS-guided transgastric approaches are considered to drain the viable pancreas upstream and allow passage of pancreatic secretions. However, this is often technically challenging due to a variety of reasons. In the following video, we will present two cases in which the presence of a fluid collection was used to facilitate EOS-guided ductal drainage in Disconnected Pancreatic Doct Syndrome. 63-year-old female with a history of recurrent acute pancreatitis with a recent episode of necrotizing pancreatitis complicated by Disconnected Pancreatic Doct Syndrome presents with acute abdominal pain, nausea and vomiting, as well as elevated lipase. CT imaging of the abdomen revealed the presence of a 3.9 cm necrotic fluid collection in the body of the pancreas along with the dilated pancreatic duct at the tail of the pancreas measuring up to 0.5 cm. On MRCP, the necrotic fluid collection seems to be in communication with the dilated pancreatic duct at the tail. Pancreatic ductal disruption was also evident on a recent RCP done showing lack of opacification of the upstream pancreatic duct distilled to the area of disruption. Patient's imaging and presentation were overall consistent with Disconnected Pancreatic Doct Syndrome complicated by necrotic collection. Patient was referred for treatment of Disconnected Pancreatic Doct Syndrome. It was elected to intervene on the pancreatic duct upstream of the disruption using an EOS-guided approach. EOS images of the mildly dilated pancreatic duct in the tail along with the 3.9 cm necrotic fluid collection in the body also filled with debris. EOS-guided pancreatic oestrostomy was initially considered. The main pancreatic duct in the tail was punctured with a 19 gauge of a knee needle and contrast injected. The necrotic collection in the pancreatic body also filled with contrast indicating communication with the main pancreatic duct at the tail. As the angle to the pancreatic duct in the tail was acute, EOS-guided pancreatic oestrostomy was not feasible. And given the communication between the main pancreatic duct and the necrotic collection to which the pancreatic juices were flowing into, it was elected to drain the collection through a transgastric approach. After puncturing the gastric wall, the tip of the catheter was visualized well and advanced distillate inside the collection. A 15 x 10 mm cotri-assisted lumen opposing metal stand was then deployed into the collection thus creating the cis-gastrostomy. A 0.035 inch guide wire was then advanced through the lumen opposing metal stand and was allowed to coil within the collection under fluoroscopy. A 7 in French 5 cm double pigtail plastic stand was then deployed co-axially within the lumen opposing metal stand and confirmed to be in good position under fluoroscopy. Here is an endoscopic view of the deployed LAMS and co-axial double pigtail plastic stand. Following the procedure, there were no reported adverse events. The patient tolerated a soft diet and achieved good pain control. Two months following discharge, the patient showed marked clinical improvement and CDE showed resolution of the previous necrotic collection. As such, an NGD was performed where the LAMS was removed while leaving the double pigtail plastic stand for indefinite treatment of disconnected pancreatic duct syndrome. 63-year-old male with over 40-pack-year tobacco use and history of recurrent acute pancreatitis with a recent episode of necrotizing pancreatitis complicated by walled-off necrotic fluid collection status post-EU as guided in the image two months ago, presented with acute abdominal pain, inability to tolerate oral intake, as well as elevated lipase. CT imaging of the abdomen revealed acute inflammatory changes in the head of the pancreas along with a 3.5 cm mixed fluid collection in the neck that appears to be in communication with the mildly dilated main pancreatic duct at the tail. On serotonin-stimulated MRCP, the pancreatic duct can be seen traveling into and out of the collection but is not seen traveling through it, representing disruption of the main pancreatic duct. A diagnosis of acute pancreatitis with mixed fluid collection along with disconnected pancreatic duct syndrome was made. An ERCP for evaluation of this area was performed. There was a round collection in the body of the pancreas consisting of ductal disruption. Prior placement across the disruption was attempted but unsuccessful. As such, the patient was planned for an EUS-guided pancreatic oogastrostomy. The mildly dilated main pancreatic duct was successfully punctured under EUS guidance with a 19-gauge FNA needle and contrast was injected. A pancreaticogram was obtained under fluoroscopy confirming correct placement of the needle within the pancreatic duct. The needle was positioned and the 0.025 inch guide wire was advanced downstream into the area of disruption and was allowed to coil within the collection. The tract between the stomach and the pancreas was dilated with a 4mm dilation balloon in a segmental fashion. A 7-french 9cm double-pictailed plastic stand was placed into the main pancreatic duct and confirmed to be in good position. Following the procedure, there were no reported adverse events. The patient was monitored for post-ERCP pancreatitis and given strong recommendation to abstain from smoking. One month later, the patient had a recurrence of abdominal pain with elevated lipase and a CT finding of a new 7.5cm fluid collection within the capsule of the left hepatic lobe. As such, he underwent drainage of the collection via EUS-guided cystostomy with LAMS and co-axial double-pictailed plastic stand. This procedure was successful as shown by the CT imaging done at follow-up showing complete resolution of the fluid collection. The patient went into remission for 6 months before developing another episode of pancreatitis. He was instructed again on smoking being an independent risk factor for recurrent acute pancreatitis. He is planned for a stent exchange. Take-home messages Disconnected Pancreatic Duct Syndrome patients have a complicated disease course requiring frequent re-interventions. Endoscopic guided drainage of the upstream pancreatic duct can be effective in preventing recurrence. The presence of an adjacent communicating fluid collection renders a technically challenging EUS-guided approach to be more feasible.

EOS-guided management

Disconnected Pancreatic Duct Syndrome

pancreatic secretions

fluid collection

endoscopic-guided drainage