Endoscopic Retrograde Cholangiopancreatography Combined with Percutaneous Drainage in Treating Disconnected Pancreatic Duct Syndrome

Summary

The combination of ERCP and PCD can safely and effectively treat DPDS with a minimally invasive procedure. This study focuses on treating DPDS with ERCP and PCD, aiming to increase the surgical success rate through the use of the double guidewire technique and localization with methylene blue staining.

Abstract

Disconnected pancreatic duct syndrome (DPDS), resulting from pancreatic injury or disease, is increasingly prevalent and poses significant challenges in clinical management due to its associated complications: leakage of pancreatic secretions, inflammation, and infection. DPDS is characterized by the leakage of pancreatic secretions into the surrounding tissues; this leakage often results from trauma, postoperative complications, or chronic pancreatitis. The resultant complications can significantly impair a patient's quality of life, necessitating effective and innovative treatment approaches. Although traditional management strategies for DPDS include surgical repair and conservative management, these strategies are often associated with high morbidity and complications. The limitations of these conventional approaches highlight the urgent need for alternative treatment modalities that reduce both surgical invasiveness and the risks associated with surgical repair. Endoscopic retrograde cholangiopancreatography (ERCP) is a well-established technique for diagnosing and treating conditions related to the biliary and pancreatic ducts. Given these challenges, exploring new diagnostic and therapeutic techniques is critical. Recent literature suggests that the combination of ERCP with percutaneous drainage (PCD) techniques may offer a promising alternative, potentially improving outcomes for patients suffering from DPDS. This study aims to investigate the efficacy and safety of ERCP combined with percutaneous drainage in the treatment of DPDS, providing novel insights into its clinical application.

Introduction

DPDS was first described by Kozarek¹. The most common underlying cause of disconnected pancreatic duct syndrome (DPDS) is acute necrotizing pancreatitis. The incidence of DPDS in patients with necrotizing pancreatitis ranges from 16.0% to 46.3%^2,3. Clinical manifestations include ongoing pancreatic duct leaks; episodes of recurrent obstructive pancreatitis; recurrent fluid collections around the pancreas, including pseudocysts; and impairment of pancreatic exocrine and endocrine functions. Additionally, patients may develop pancreatic ascites or pancreatic pleural effusion; pseudoaneurysms causing hemorrhage in peripancreatic vessels; and portal hypertension related to pancreatic pathology.

In patients with DPDS caused by acute necrotizing pancreatitis, the disease progression is complex and prolonged, often involving a sequence of pancreatic transmural necrosis, pancreatic duct interruption, and encapsulated pancreatic necrosis⁴. Currently, there is no standard treatment plan for DPDS patients; therefore, early diagnosis and treatment are crucial.

DPDS treatment mainly includes conservative treatment, percutaneous drainage (PCD), endoscopic treatment, and surgical treatment. Currently, endoscopic treatment, which includes endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), has become a popular approach for DPDS. Compared to EUS-guided transmural drainage, ERCP more closely matches the natural drainage of the duodenal major papilla⁵. However, some studies have found that the failure rate of ERCP alone in treating DPDS can reach up to 75%⁶, and only about one-third of patients succeed with PCD drainage alone⁷. The combination of ERCP and PCD can significantly improve treatment outcomes⁸.

In this study, we focused on treating DPDS with ERCP and PCD, and increased the surgical success rate through the double guidewire technique and localization with methylene blue staining. We presented a case to illustrate our surgical techniques and intraoperative guidance methods; we also assessed the patient's treatment outcomes. A 64-year-old male patient had a lengthy history of pancreatitis and pancreatic fistula. The patient underwent laparoscopic surgery to remove necrotic tissue and drain fluid from acute biliary necrotizing pancreatitis 3 months prior to the hospital visit. The surgery also included gastrostomy and jejunal feeding tube placement. Additionally, the patient received three procedures of PCD to remove necrotic pancreatic tissue. After the surgery, the PCD was draining about 300 mL of pancreatic fluid each day. Though acute pancreatitis was resolved, the PCD was still draining clear pancreatic fluid. The patient underwent ERCP and PCD through the double guidewire technique and localization with methylene blue staining. The follow-up 12 months post-procedure confirmed sufficient and effective drainage and complete healing of the sinus tract, minimizing the risk of complications.

Through this report, we aim to demonstrate the feasibility and effectiveness of this combined approach and provide valuable insights into the endoscopic treatment of DPDS. Ultimately, the findings of this study may help guide clinical decision-making and improve the success rate of ERCP in this challenging area of medicine.

Protocol

This study was approved by the Ethics Committee of the Fifth Affiliated Hospital of Southern Medical University. Written informed consent was obtained from the patient before the procedure.

1. Patient selection

1. Confirm the indication for surgery. Here, the PCD was draining about 300 mL of pancreatic fluid each day after the initial surgery.

2. Informed consent

1. Discuss the surgical procedure, risks, benefits, and alternatives with the patient, and ensure that informed consent is obtained.

3. Preoperative workup

1. Perform routine laboratory tests, including complete blood count and coagulation profiles.
2. Perform preoperative enhanced computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) studies to localize pancreatic fluid collections and evaluate the main pancreatic duct (MPD).

4. Operative setup

1. Administer general anesthesia following standard protocols.
2. Position the patient in the left lateral position, which is the regular position of ERCP.
3. Prepare the duodenoscope, X-ray machine, electronic bile duct scope, and surgical materials.

5. Surgical technique

1. Insert the duodenoscope.
   1. Pass the endoscope through the throat, esophagus, and stomach in sequence.
   2. Identify the sunset sign-a characteristic endoscopic feature-at the pylorus, then enter the duodenum and conduct a thorough examination to assess for ulcers or other pathologies of the digestive tract.
   3. Next, locate the main duodenal papilla and position the endoscope appropriately to facilitate further evaluation.
2. Intubate the patient.
   1. Insert the catheter at the 1 o'clock position. After gently pushing the guidewire through the catheter, pull back on the syringe plunger to aspirate and check for pancreatic ductal fluid.
   2. Then, use an X-ray to confirm that the guidewire is in the pancreatic duct (Figure 1A). Then, inject the appropriate contrast agent to clearly visualize the MPD.
      NOTE: During the intubation process, the lead surgeon and the assistant need to coordinate their actions closely. The orientation of the intubation and the assistant's tactile sensitivity are both very important. It is important to avoid forceful intubation or forceful guidewire insertion.
   3. Make a 2 mm incision on the major duodenal papilla at the 1 o'clock position with a scalpel. Then, slowly inflate a balloon catheter to dilate the papilla for 1 minute, maintaining the inflation pressure at 2 atmospheres.
3. Explore using an electronic bile duct scope.
   1. Inject an appropriate contrast agent through the PCD tube until the DPDS cavity is fully visualized. Confirm the anatomical relationship between the MPD and the DPDS cavity using X-ray imaging (Figure 1A).
   2. Next, insert a zebra guidewire. Gradually dilate the sinus tract to 12 French (Fr) along the guidewire using a sheath.
   3. After inserting the endoscope through the sheath, carefully explore the DPDS cavity and locate the endoscopic guidewire.
   4. During the exploration with the bile duct scope, continuously inject saline and use intermittent negative pressure washing to keep a clear view. Then, if the DPDS cavity is straightened, use a stiff bile duct scope.
4. Bridge the disrupted pancreatic duct.
   1. First, repeatedly adjust the scalpel and guidewire under the endoscope, and confirm via X-ray if it can access the DPDS cavity. If unsuccessful, slowly inject methylene blue into the DPDS cavity wall via the MPD (Figure 1B).
   2. Use a choledochoscope to examine the first stained area of the cavity wall (Figure 1C). Gently break the stained cavity wall with a zebra guidewire and a stone retrieval basket until the methylene blue flowing smoothly into the DPDS cavity is seen.
   3. Then, adjust the endoscopic knife and guidewire to enter the cavity through the perforation (Figure 1D). Finally, guide the endoscope wire out of the body (Figure 1E).
   4. Perform preoperative imaging examinations to determine the thickness of the DPDS cyst wall and its relationship to the MPD. If the MPD is near the cyst cavity and the cyst wall is thin, first use an endoscopic knife and a guidewire to break the cyst wall.
   5. When the cyst wall thickens and results in poor staining with methylene blue, repeatedly thin the cyst wall with an endoscopic scalpel and guidewire. If that does not work, directly puncture the cyst wall with the tail end of a black loach guidewire through a peroral cholangiopancreatoscopy.
   6. After the endoscopic guidewire enters the cystic cavity, further advance it through the cyst to the body surface. If that does not work, retrieve the endoscopic guidewire using a basket for stone retrieval under direct visualization using a choledochoscope. Then pull it out to the body surface.
5. Place the pancreatic duct stent.
   1. Once the bridging is successful, use a 10Fr sheath following the tip of the endoscopic guidewire to dilate the tear in the cyst wall where the DPDS meets the MPD under X-ray guidance. This will make it easier to place the pancreatic duct stent and widen the passage.
   2. Choose a pancreatic duct stent (7 Fr, 10 cm) based on the diameter of the main duct and how far the duodenal papilla is from the cyst cavity, making sure that the stent goes into the DPDS cyst cavity by over 2 cm (Figure 1F).
6. Place a bile duct stent and a PCD tube.
   1. After inserting the catheter into the bile duct at the 11 o'clock position, make a 2 mm incision in the duodenal papilla in the 11 o'clock direction with a scalpel, then slowly dilate the papilla using a balloon for 1 min, keeping the pressure at 3 standard atmospheres, and place a plastic stent (7 Fr, 10 cm) in the bile duct.
   2. Insert a silicone drainage tube (18Fr) 8 cm into the cystic space under X-ray guidance through the original skin sinus tract of the PCD (Figure 1F) and then secure it. During the procedure, take care to avoid displacing the previously placed stent in the pancreatic duct.

6. Postoperative care

1. Monitor vital signs, fluid balance, complete blood count, and pancreatitis markers in the postoperative period. If acute pancreatitis and elevated infection markers occur, initiate antimicrobial therapy and symptomatic treatment, including inhibition of pancreatic enzyme activity.
2. Encourage early ambulation and remove the PCD drainage tube on the third day after the operation.
3. Conduct follow-up for any discomfort, such as abdominal pain or fever, and address any postoperative complications.
   1. After 6 months, perform the second ERCP to replace the pancreatic duct plastic stent (10 Fr, 12 cm).
   2. After 12 months, perform the third ERCP to place a nasal pancreatic duct catheter (8.5 Fr) for temporary drainage.
      NOTE: After the third ERCP and placement of the stent, the overall treatment duration was 1 year for the case described here. Ultimately, the DPDS was completely resolved.

Results

From March 2023 to May 2025, ERCP + PCD was performed on 2 patients in our department. The key to a successful surgery lies in whether the junction between the MPD and the cyst can be successfully breached. In one patient, the endoscopic guidewire was successfully navigated into the cyst cavity after several attempts during treatment. However, in this patient of this study, despite several attempts with the endoscopic guidewire, it could not enter the cyst cavity. The cyst wall junction was marked with methylene blue, an...

Discussion

Currently, endoscopic treatment is a popular option for treating patients with DPDS, which mainly includes ERCP, EUS, ERCP with PCD, and ERCP with EUS. According to different drainage methods, it is mainly divided into transpapillary drainage and transmural drainage.Transpapillary drainage is physiologic and more attractive. Compared with transwall drainage, transpapillary drainage does not require creating an alternative nonanatomical route of drainage. ERCP combined with PCD is one of the methods of transpapillary drai...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Balloon catheter	Boston Scientific Corp.	M00558610	Dilate the papilla
Bile duct stent	Boston Scientific Corp.	M00539220	Biliary drainage
Catheter and guidewire	Boston Scientific Corp.	M00583100	Used for cannulation of MPD and bile duct.
Cholangiopancreatoscopy	Scivita Medical Corp.	SCV-P-02	Explore MPD
Duodenoscope	Sonoscape Medical Corp.	ED-5GT	Used for ERCP
Electronic bile duct scope	Scivita Medical Corp.	SCC-BA2	Explore DPDS cavity
Nasal pancreatic duct catheter	Boston Scientific Corp.	M00540140	Pancreatic duct drainage
Pancreatic duct  stent (10 Fr, 12 cm)	Olympus Corporation	PBD-234-1012	Pancreatic duct drainage
Pancreatic duct stent (7 Fr, 10 cm)	Olympus Corporation	PBD-234-0710	Pancreatic duct drainage
PCD tube	Jinan Zhongkangshun Medical Devices Co.,Ltd.	C type Fr18	DPDS cavity drainage
Sheath	Jinan Zhongkangshun Medical Devices Co.,Ltd.	A type Fr18	Dilation of the sinus and rupture of the DPDS sac wall
Stone retrieval basket	Precision medical instruments	PNRC-2040-D-W	Break the DPDS capsule wall
Zebra guidewire	Jinan Zhongkangshun Medical Devices Co.,Ltd.	D4 type 0.032	Guided choledochoscope and DPDS cyst wall rupture