Percutaneous ablative techniques for definitive treatment of disconnected duct syndrome in necrotizing pancreatitis: review and institutional experience

Review the evolving therapeutic approach for disconnected pancreatic duct syndrome (DPDS) and the role of percutaneous alcohol and cryoablation as definitive management.

Provide a pictorial review of cases performed at our institution and briefly outline techniques.

Identify patients who are candidates for intervention and anatomic considerations.

Background:

Disconnected pancreatic duct syndrome (DPDS) is a morbid complication of severe necrotizing pancreatitis caused by necrosis, resulting in a segment of pancreas and main pancreatic duct disconnected from the gastrointestinal tract. The current standard of care for DPDS is distal pancreatectomy, with endoscopic transmural stenting or surgical transgastric drainage often attempted first given the morbidity and mortality associated with resection {1}. Limited studies have reported efficacy of ablative techniques in the management of pancreatic cancer {2}. We describe pancreatic ablation successfully performed at our institution as definitive treatment of DPDS.

Clinical Findings/Procedure Details:

We present our institutional case series of patients with necrotizing pancreatitis complicated by DPDS treated with percutaneous ablation of an isolated pancreatic remnant (n=8 – 2 cryoablation, 6 chemical). All patients were deemed poor surgical candidates or failed prior distal pancreatectomy with recurrent peripancreatic fluid collections. Cryoablation or chemical ablation (alcohol) was determined based on the available percutaneous approach and the proximity of the remnant pancreas to the adjacent critical structures. CT was used to localize the isolated pancreatic tissue in either the supine or prone position, based on the patient’s anatomy. A direct percutaneous approach was used in most cases, with percutaneous trans-splenic chemical ablation performed when a direct approach was unsafe. For the remnants larger than 3 cm, cryoablation was preferred unless deemed unsafe due to risk of injury to the surrounding colon and small bowel, as larger remnants required repeat sessions with ethanol ablation. 17-G Acuvance catheters and 2-3 Galil Ice Rod Plus cryoablation probes with 2-3 total freeze/thaw cycles were used for cryoablation cases. Chemical ablation was performed using 2-5 mL absolute ethanol and tantalum powder. All cases were technically successful and clinical success – defined as resolution of peripancreatic fluid collections – was achieved in all patients.

Conclusion and/or Teaching Points:

Percutaneous ablation of the isolated pancreatic remnant is an effective definitive treatment for necrotizing pancreatitis complicated by DPDS.