Endoscopic therapy of complete and partial pancreatic duct disruptions

Although ductal disruptions are common in persistent, smoldering pancreatitis, pancreatic necrosis, or acute pancreatic fluid collections, chronic pancreatic fistulas have traditionally been defined as internal or external. Closure of these fistulas depends upon site and size of duct disruption, superinfection, downstream obstruction as a consequence of stricture or stone, or the presence of the "disconnected duct syndrome." Medical treatment is aimed at minimizing pancreatic secretion (low fat diet, pancreatic enzymes vs. NPO/hyperalimentation, octreotide, repeated/chronic drainage procedures). Resective or decompressive pancreatic surgery requires preoperative ERCP to define the anatomy. More recently, transpapillary endoprostheses have been used in a patient subset and deserve additional consideration in patients who fail to respond to conservative measures.