Early interventions for disconnected pancreatic duct syndrome in acute pancreatitis

Aim. To determine the indications for early interventions in patients with acute pancreatitis and disconnected pancreatic duct syndrome, and evaluate their effectiveness. 

Material and methods. The study included 180 patients: type 1 of the necrosis configuration was detected in 150, type 2 – in 30. The diagnosis of disconnected pancreatic duct syndrome was established according to CT data (type 1 of pancreatic necrosis) and high activity of alfa-amylase in fluid collections. The patients underwent various treatments: only conservative (50), percutaneous punctures / drainage of collections (33), surgery (54), 2-stage treatment (percutaneous punctures / drainage at 1–2 weeks and sequestrectomy at 3-5 weeks) – in 25. In 18 patients with type 1 necrosis, endoscopic recanalization of the pancreatic duct through the zone of transverse necrosis was performed on days 1–4 from the onset of the disease.

Results. The overall mortality rate was 22.8%: with type 1 of the necrosis configuration – 26.6%, with type 2 – 3.3%, p < 0.01. Conservative treatment and percutaneous punctures were effective in 22 (73%) patients with type 2 necrosis configuration and in 53 (35%) with type 1 with shallow necrosis and the absence of high alpha-amylase activity in the fluid. In patients with disconnected pancreatic duct syndrome, the mortality rate in 2-stage treatment was 9%, which was significantly lower than in early (58%) and late (39%) surgery.

Conclusion. The indication for early intervention is the high activity of alpha-amylase in fluid collections with type 1 necrosis configuration. Early interventions should be minimally invasive and aimed at transferring an internal fistula to an external one. This prevents the progression of parapancreatitis and allows to perform stage 2 (sequestrectomy) at a later date. Two-stage treatment significantly reduces mortality compared to early and late surgery.

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