Complete disruption of the main pancreatic duct: endoscopic management

Complete disruption of the main pancreatic duct is an unusual event in the course of acute or chronic pancreatitis. Endoscopic management has already proven effective in the treatment of partial ruptures.

Thirteen patients presented over a 7-year period with acute (9 patients) or chronic (4 patients) pancreatitis complicated by complete disruption of the main pancreatic duct and cyst formation. Endoscopic treatment was attempted in 12. Treatment varied depending on the site of the rupture and accessibility of the pseudocyst and consisted either of transpapillary drainage (3), cystogastrostomy (3), cystoduodenostomy (2), or combined procedures (4) when one of these procedures did not induce significant decrease in collection size. Long-term results were obtained by observing the patients with ultrasound, CT, ERCP, and clinical evaluation.

Short-term results were excellent with complete cyst resolution and clinical recovery in all but one patient treated by endoscopy. Two patients had pseudocyst infection successfully treated by drainage and antibiotics. Long-term follow-up was available for 11 patients (mean duration, 30.2 months; range, 12 to 72 months) without relapsing clinical symptoms or pseudocyst.

Endoscopic management is effective and safe for treating patients with complete main pancreatic duct disruption. A double drainage combining transpapillary drainage and cystoenterostomy must be done in selected instances, especially when rupture occurs in the setting of chronic pancreatitis with stricture or stone distal to the rupture.