Disconnected Pancreatic Duct Syndrome | Cirugía Española (English Edition)

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array:2 [ "paginaInicial" => "4" "paginaFinal" => "10" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Jose Manuel Ramia, Joan Fabregat, Manuel Pérez-Miranda, Joan Figueras" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Jose Manuel" "apellidos" => "Ramia" "email" => array:1 [ 0 => "jose_ramia@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Joan" "apellidos" => "Fabregat" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Manuel" "apellidos" => "Pérez-Miranda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Joan" "apellidos" => "Figueras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Bellvitge, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Gastroenterología, Hospital Río Hortega, Valladolid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Josep Trueta, Gerona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome del ducto pancreático desconectado" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 776 "Ancho" => 950 "Tamanyo" => 97192 ] ] "descripcion" => array:1 [ "en" => "Patient <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. PP: pancreatic prosthesis. PB: biliary prosthesis. CG: cystogastrostomy." ] ] ] "textoCompleto" => "A clinical entity, which had already been referred to in medical literature, consisting of an anatomical situation where there is no continuity of the pancreatic duct between viable pancreatic tissue and the gastrointestinal tract, caused by duct necrosis after severe acute pancreatitis and treated medically, by percutaneous drainage or by necrosectomy,<a class="elsevierStyleCrossRefs" href="#bib0005">1–8</a> was named for the first time by Kozarek et al. as disconnection of the pancreatic duct or disconnected pancreatic duct syndrome in 1991. The isolated viable pancreatic segment continues its exocrine function, causing inflammatory intra or peripancreatic collections or an external pancreatic fistula.<a class="elsevierStyleCrossRefs" href="#bib0025">5–11</a>In addition to acute pancreatitis, other possible aetiologies of DPDS could be chronic pancreatitis, pancreatic trauma, pancreas divisum and other causes.<a class="elsevierStyleCrossRefs" href="#bib0010">2,9,12,13</a> Other terms used to define this syndrome are: disconnected pancreatic tail syndrome and disconnected left pancreatic remnant.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>There are no clear epidemiological data on the real incidence of DPDS; approximately 10% and 30% of patients with severe acute pancreatitis could develop DPDS. The incidence of patients diagnosed with DPDS is increasing.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Existing literature is scarce; the terminology is confusing and therapeutic algorithms are not clearly defined.<a class="elsevierStyleCrossRefs" href="#bib0010">2,4,7,9</a> We have performed a systematic review of the literature on DPDS.SearchWe carried out a search on Pubmed (1966–2012) for articles in English and Spanish using the terms «disconnected pancreatic duct syndrome» (17) and «disconnected pancreas» (29) and only 15 of the articles we revised were relevant. Given the few citations, the references of these articles were revised for more information on this subject which had not been included in the search terms. Finally, we revised a total of 23 articles. There are no randomised trials, clinical guides or meta-analysis of DPDS.DefinitionIn acute pancreatitis, pancreatic glandular necrosis has traditionally been considered a determinant of severity. However, in some patients, necrosis of the ductal epithelium is more severe and significant than glandular necrosis.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> DPDS occurs after a variable percentage of pancreatic parenchyma has necrosed, usually in a central location, which causes a ductal lesion that results in the distal remnant becoming disconnected from the pancreatic duct and its exocrine production being unable to drain into the gastrointestinal tract. All of this results in the formation of an intra-abdominal collection or external pancreatic fistula (EPF).<a class="elsevierStyleCrossRefs" href="#bib0025">5,6,14</a> When there is an EPF there is usually no communication between the fistula and the proximal duct and the fistula is exclusively fed by the distal remnant.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> In Howard's series of 27 patients with DPDS, 70% present with EPF and 30% with intra-abdominal collection.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>DPDS usually occurs after surgical necrosectomy due to acute pancreatitis or walled-off pancreatic necrosis (WOPN) (50%–75% of patients with DPDS).<a class="elsevierStyleCrossRef" href="#bib0010">2</a> 15%–25% of patients who have undergone necrosectomy present EPF.<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a> If these data are real, the question is why do we not find more patients with DPDS,<a class="elsevierStyleCrossRefs" href="#bib0010">2,9</a> since it can occur in patients treated with percutaneous drainage as well as in operated patients. It is likely that paucisymptomatic or wrongly diagnosed patients are the reason for the low number of patients diagnosed with DPDS.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The existence of unoperated cases indicates that the cause of DPDS is the ductal damage caused by pancreatitis per se and not surgical or percutaneous intervention.DiagnosisCorrectly diagnosing DPDS is essential, as its treatment is different from that used in other post-pancreatitis intra or peripancreatic collections, pseudocysts, for example, or post-necrosectomy EPF necrosectomies caused by ductal obstruction which can be resolved with a transpapillary prosthesis placed using ERCP,<a class="elsevierStyleCrossRefs" href="#bib0035">7,15</a> and from so-called partial disruptions of the duct, which should not be considered DPDS as they are not really ductal disconnections.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> This difficulty in diagnosis makes it enormously complicated to reach conclusions when results are compared, as it is likely that wrongly diagnosed patients have been included in the series.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>The existence on computerised axial tomography (CT) of a thin and small bridge of viable pancreatic tissue, compressed on the lower or posterior side, can suggest the possibility of a misdiagnosis of DPDS as this is showing us a partial disruption.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Fluid collections which compress the gland usually displace the duct that enters them at an oblique, not a straight, angle to the collection wall, as occurs in DPDS.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Methods used for diagnosing DPDS are: CT, nuclear magnetic resonance (MRI) and endoscopic retrograde cholangio-pancreatography (ERCP).<a class="elsevierStyleCrossRefs" href="#bib0010">2,6,16</a> It has been suggested that ERCP be replaced with nuclear magnetic cholangio resonance (MRC) with secretin stimulation, but the former is more sensitive in demonstrating ductal leakage, although it is more invasive.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6,9,10,13,14,16</a> Fistulography can be useful in some cases where there is EPF to differentiate between a terminal and lateral fistula.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>The traditional diagnostic criteria for DPDS are: discontinuity of the main pancreatic duct with evidence of viable distal pancreatic tissue and presence of a persistent fluid collection in the imaging methods, or discontinuity of the main pancreatic duct on ERCP and the impossibility of accessing or cannulating the distal duct.<a class="elsevierStyleCrossRefs" href="#bib0020">4,7–9,11,14</a> A priori and traditionally, when the endoscopist was unable to cross the disconnected area with a guide or drain it was evidence that the duct was completely disconnected and not merely disrupted, although nowadays technical sophistication sometimes makes it possible for the disconnected distal remnant to be cannulated.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9,11</a>More specific criteria have been proposed so that we have a DPDS if:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-The CT shows necrosis or a collection in the neck or body of the pancreas of at least 2cm of pancreas and viable distal pancreatic tissue from the area of necrosis, or a pancreatic duct entering the collection at an angle of 90°.<a class="elsevierStyleCrossRefs" href="#bib0010">2,6,14</a></li><li class="elsevierStyleListItem" id="lsti0010">-Extravasation of contrast material injected into the pancreatic duct in the pancreatography obtained by ERCP, endoscopic or intraoperative ultrasound, or complete section/disconnection of the duct in the distal remnant.<a class="elsevierStyleCrossRefs" href="#bib0010">2,6,14</a></li></ul>In a CT scan performed two weeks after the onset of acute pancreatitis, some details suggestive of DPDS could already be recognised, but they were not definite.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> The distal pancreatic duct can be seen to be either dilated or otherwise in the different imaging tests.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Necrosis of less than 2cm with no initial ductal lesion can heal without involving the duct but subsequently fibrosis and tissue scarring can cause stenosis of the pancreatic duct which can result in recurrent pancreatitis, although this cannot be referred to as DPDS.<a class="elsevierStyleCrossRefs" href="#bib0010">2,6,8</a>The most common location of DPDS is the neck of the pancreas, especially in gallstone pancreatitis; this might be due to this area of the pancreas being particularly vascular.<a class="elsevierStyleCrossRefs" href="#bib0010">2,9,10</a> Only the dorsal pancreatic artery feeds this area, whereas other regions of the pancreas are vascularised by more than one artery. A disruption of blood flow during pancreatitis causes necrosis and it is possible for DPDS to develop as a result of a ductal lesion.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Although the anatomical disposition with sharp angulation of the duct from upward anterior to transverse posterior can also contribute towards this being the most affected area.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>Clinical FeaturesThe existence of a collection or EPF after a necrosectomy or drainage of infected pancreatic necrosis which does not resolve within a reasonable period of time should suggest the possibility of DPDS.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The volume of the fistula dictates the amount of viable pancreatic tissue.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>The clinical features are not specific and the following symptoms have been described: abdominal pain, nausea and vomiting, dietary intolerance and weight loss.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Lithiasis is the most frequent aetiology in pancreatitis which causes DPDS.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> 50% of patients with WOPN treated using percutaneous drainage develop DPDS.<a class="elsevierStyleCrossRefs" href="#bib0015">3,17</a>Patients with DPDS are at greater risk of diabetes mellitus, metabolic and nutritional problems due to loss of proteins and electrolytes, and portal hypertension.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The following complications associated with DPDS have been described: recurrent pancreatic fluid collections, ascites and pseudoaneurysms.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>TreatmentTraditionally, it was thought that DPDS should be treated with surgery.<a class="elsevierStyleCrossRefs" href="#bib0020">4,9</a> But there are currently many treatment options (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>DPDS can present as a peripancreatic collection or an EPF. Treatment is different in each case. If the patient presents with a collection which does not increase in size and is asymptomatic, in principle a wait-and-see approach can be taken although symptoms usually develop as the patient is monitored.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> If the collection presents symptoms (pain, fever, recurrent pancreatitis) these must be treated, usually with endoscopic techniques if is feasible (internal drainage [cystogastric or cystoduodenostomies] or a prosthesis up to the ductal remnant). Puncture by percutaneous drainage must be avoided as this will cause an EFP which will be difficult to resolve.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>In the case of an EFP due to DPDS the steps are: medical stabilisation, establishing the anatomy of the ductal disruption and implementing medical, endoscopic or surgical treatment.<a class="elsevierStyleCrossRefs" href="#bib0050">10,17</a> Medical management (nutrition and somatostatin analogues) is slow and has a low success rate; endoscopic techniques are complex and are not always feasible; and surgery is technically difficult.<a class="elsevierStyleCrossRefs" href="#bib0020">4,15,17</a> EFP usually occurs through one of the necrosectomy drains or previous percutaneous drainage.<a class="elsevierStyleCrossRefs" href="#bib0010">2,10</a> There are no guidelines on the optimal treatment for EFP due to DPDS. It usually starts with medical treatment, then endoscopic techniques are used and if these fail, surgery is considered.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>We need to wait for at least six weeks before considering surgical treatment as we postpone surgery until pancreatic inflammation has subsided and the EFP is firmly established.<a class="elsevierStyleCrossRefs" href="#bib0025">5,10,14,18</a> Pearson et al. consider surgery in the case of a fistula greater than 100ml/day which persists three months after the onset of DPDS.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>We have summarised the various endoscopic and surgical techniques:Endoscopic TechniquesEndoscopic techniques are not diagnostic but are now therapeutic for DPDS.<a class="elsevierStyleCrossRefs" href="#bib0020">4,9</a> Furthermore, when they do not completely resolve the DPDS they can serve as a bridge prior to surgery and improve the patient's local and general conditions.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> The success rate of older series, without clearly defining DPDS, varies between 25% and 37% but has currently improved reaching 61%–75%. The results are particularly good when there are collections, but less good when there is EPF.<a class="elsevierStyleCrossRefs" href="#bib0010">2,4,9,11,17</a> Those who defend endoscopic techniques highlight good results, no mortality, low morbidity (25%) and although the relapse rate is close to 50% there is the possibility of repeating the procedure<a class="elsevierStyleCrossRefs" href="#bib0045">9,11,17</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The basic initial technique consists of ERCP and placement of a prosthesis but the distal remnant must be drained, which is usually very difficult. We should remember that simple transpapillary drainage is not helpful. As we have mentioned, traditionally it was considered that being unable to cannulate the distal remnant was diagnostic of DPDS; endoscopic techniques having been perfected, meaning that currently, in some patients, it is possible to cannulate the ductal remnant (10%–25%).<a class="elsevierStyleCrossRefs" href="#bib0045">9,16</a> And, as we have mentioned, ductal transpapillary drainage is very effective in lateral fistulas which are not true DPDS but it is not usually possible to resolve the terminal fistulas.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>When distal cannulation has not been feasible, there are other technical options in the literature based on internal drainage by ultrasound endoscopy; i.e., locating the collection and the duct by means of ultrasound endoscopy and then connecting it with the digestive tract (stomach or duodenum), placing a prosthesis which joins both.<a class="elsevierStyleCrossRefs" href="#bib0095">19,20</a> The different options are: performing transgastric pancreatography guided by endoscopic ultrasound to locate the duct and then drain the dilated duct via transgastric route<a class="elsevierStyleCrossRefs" href="#bib0045">9,20</a>; perform endoscopic ultrasound guided drainage from the fourth duodenal portion<a class="elsevierStyleCrossRefs" href="#bib0045">9,19,21</a> or use rendezvous techniques combining interventional and endoscopic radiology.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> 20%–50% of patients who have undergone endoscopic ultrasound drainage develop diabetes mellitus.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>In cases treated with internal drainage, there is no consensus on the type of drain that should be used. Permanent drains between the collection and the digestive tract have been used with good results, although there is the danger of migration or infection.<a class="elsevierStyleCrossRefs" href="#bib0015">3,17</a> Prostheses which are not permanent can become obstructed and cause therapeutic failures in the short or medium term.<a class="elsevierStyleCrossRef" href="#bib0065">13</a>Embolisation of the distal pancreatic duct with cyanoacrylate has been performed in very few patients with acceptable results: although it does close the EFP, it does not solve the problem of the disconnected distal remnant.<a class="elsevierStyleCrossRefs" href="#bib0050">10,14,17,22,23</a>Surgical TechniquesSurgery can be considered the definitive solution in the event that endoscopic techniques fail or as a first option.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> The surgical treatment of DPDS is criticised principally because of its rate of morbidity (0%–14%) and mortality (0%–8%); its main advantage is its 80% success rate.<a class="elsevierStyleCrossRefs" href="#bib0010">2,10,15</a> Resection techniques (distal pancreatectomy with or without splenectomy) and by-pass techniques (Roux-en-Y fistulojejunostomy, pancreaticojejunostomy or pancreaticogastrostomy) are possible surgical options.<a class="elsevierStyleCrossRefs" href="#bib0010">2,4,5,7,14</a> It is recommended that a cholecystectomy be performed if this has not taken place previously.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>By-pass techniques have several advantages: in theory they are simpler (less intraoperative bleeding, less transfusion and less operating time), they have a lower rate of postoperative complications (6%) and shorter average hospital stay, and they preserve endocrine and exocrine function with a lower rate of postoperative diabetes.<a class="elsevierStyleCrossRefs" href="#bib0010">2,5,12,14</a> Although in the series of Murage et al., they present a higher rate of intra-abdominal abscesses than resection techniques.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The average success rate of by-pass techniques as a whole is around 80%.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> In the only series which combines the three by-pass options no differences are observed in terms of results using any one particular technique.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>In the series of Pearson et al. of seven fistulojejunostomies (FJ) there was no recurrence of pancreatitis, dilatation of the pancreatic duct, or exocrine insufficiency, but half the patients presented with moderate endocrine insufficiency, which was treated with oral anti-diabetic drugs.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> In another short series of FJ, there was a 77%–100% success rate.<a class="elsevierStyleCrossRefs" href="#bib0050">10,18</a> The authors of these series on FJ underline the need to have a well-formed fibrous tract in order to perform the FJ, it is therefore important to wait a reasonable amount of time before undertaking the operation.<a class="elsevierStyleCrossRefs" href="#bib0025">5,18</a> Murage et al. recommend using a duct-to-mucosa by-pass as they believe this to be better than FJ, although it is sometimes difficult to perform, as it calls for a small pancreatic resection.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The main disadvantage of pancreatic resection is the loss of pancreatic tissue, as this can further compromise exocrine and endocrine function which has often already been damaged, and the difficulty of a resection in an organ with prior pancreatitis, generally increasing the incidence of intraoperative bleeding and morbidity (19%) compared to by-pass techniques.<a class="elsevierStyleCrossRefs" href="#bib0020">4,10</a> Howard et al. recommend resection when there is thrombosis of the splenic vein or left portal hypertension, when malignancy cannot be ruled out and in patients with obstructive pancreatitis.<a class="elsevierStyleCrossRefs" href="#bib0010">2,8</a> Murage adds a further indication: a very small ductal remnant (<6cm).<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The success rate of resection techniques is approximately 75%.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>Recurrence of pancreatic fistula is greater in the pancreatectomy group.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> There is mixed data on the rate of re-laparotomy for both types of techniques in the few published series<a class="elsevierStyleCrossRef" href="#bib0025">5</a> (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 1–3</a>; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>ConclusionDPDS is a clinical entity that usually occurs after severe acute pancreatitis and which presents with the appearance of a collection or EFP. Correct diagnosis is essential and it should be distinguished, from pancreatic pseudocyst, partial ductal disruption, WOPN and other post pancreatitis symptoms by CT scan and MRC. Traditionally treatment was surgical but now it can be endoscopic, using either ERCP or, usually, internal endoscopic ultrasound guided drainage. Endoscopic techniques present low morbimortality but are less successful in the long term than surgical techniques. By-pass or resection surgery is more effective but has greater morbimortality. There are no internationally- agreed therapeutic algorithms but it is increasingly more common to use endoscopic techniques first and if they fail, consider surgery. DPDS is another disease where it has been demonstrated that multidisciplinary collaboration among radiologists, gastroenterologists and surgeons is fundamental for the care of patients with complex pancreatic disease.Conflict of InterestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres314995" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec297734" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres314994" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec297735" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Search" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Definition" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Diagnosis" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Clinical Features" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Treatment" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Endoscopic Techniques" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Surgical Techniques" ] ] ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of Interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-02-06" "fechaAceptado" => "2013-02-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec297734" "palabras" => array:5 [ 0 => "Disconnected pancreatic duct syndrome" 1 => "Pancreas" 2 => "Surgery" 3 => "Pancreatitis" 4 => "Review" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec297735" "palabras" => array:5 [ 0 => "Síndrome del ducto desconectado" 1 => "Páncreas" 2 => "Cirugía" 3 => "Pancreatitis" 4 => "Revisión" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Disconnected pancreatic duct syndrome (DPDS) is characterised by disruption of the main pancreatic duct with a loss of continuity between the pancreatic duct and the gastrointestinal tract caused by ductal necrosis after severe acute necrotising pancreatitis treated medically, by percutaneous drainage, or necrosectomy.There are no clear epidemiological data on the real incidence of DPDS; approximately 10%–30% of patients with severe acute pancreatitis could develop DPDS. The existing literature is scarce, the terminology is confusing and therapeutic algorithms are not clearly defined. Both endoscopic management and surgical management have been described.We have performed a systematic review of the literature on DPDS." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La desconexión del ducto pancreático, o síndrome del ducto pancreático desconectado (SDPD), es una entidad clínica que consiste en la existencia de una situación anatómica en la que hay ausencia de la continuidad del conducto pancreático entre el tejido pancreático viable y el tracto gastrointestinal, causada por necrosis ductal tras pancreatitis aguda grave tratada mediante necrosectomía, drenaje percutáneo o médicamente.No hay datos epidemiológicos claros sobre la incidencia real de SDPD. Se ha postulado que entre un 10 y un 30% de los pacientes con pancreatitis aguda grave desarrollan un SDPD.La literatura existente sobre este tema es escasa, los términos empleados son confusos y los algoritmos terapéuticos son poco claros. Las opciones terapéuticas son endoscópicas y quirúrgicas.Hemos efectuado una revisión sistemática de la literatura sobre SDPD." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ramia JM, Fabregat J, Pérez-Miranda M, Figueras J. Síndrome del ducto pancreático desconectado. Cir Esp. 2014;92:4–10." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 650 "Ancho" => 1500 "Tamanyo" => 140898 ] ] "descripcion" => array:1 [ "en" => "SDPD:ERCP:biliary tract dilatation and leak in pancreatic body." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 776 "Ancho" => 950 "Tamanyo" => 97192 ] ] "descripcion" => array:1 [ "en" => "Patient <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. PP: pancreatic prosthesis. PB: biliary prosthesis. CG: cystogastrostomy." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1107 "Ancho" => 1500 "Tamanyo" => 208500 ] ] "descripcion" => array:1 [ "en" => "(A and B) Endoscopic retrograde pancreatography (ERCP): (A) Duct of Wirsung with complete transection in yuxta-cephalic body with the head of the duct opacified, and no fill in body and tail. (B) Endoscopic catheter tip (sphincterometer) in the transection. Opacification of residual collection and Wirsung duct in the tail via percutaneous catheter. (C and D) Opacification of residual collection and Wirsung duct in the tail via the percutaneous catheter. (C and D) Endosonographic pancreatography (ESCP) via transgastric puncture. (C) Injection of contrast through a dilator introduced using transgastric Seldinger up to the duct of Wirsung in the tail. (D) Plastic pancreatogastric prosthesis, on guide (pancreatico-gastrostomy)." ] ] 3 => array:6 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "DI: internal bypass; Endo: endoscopy; ND: not available; PA: acute pancreatitis; PD: distal pancreatectomy." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Gender (% males) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Aetiology, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Previous necrosectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Presentation of DLPR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type of surgery/endo. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Morb. (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mort. (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Success (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Follow-up (months) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="12" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical series</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Howard (2001) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 PA (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pseudocyst: 70%Pancreatic fistula: 30% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 PD13 DI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NDND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 PD7 DI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93 PD100 DI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PD: 19DI:17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Murage (2010) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 PA (73)17 PC (22) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42/59 (71%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pseudocyst: 53%Pancreatic fistula: 34%Pancr. obstructive: 13% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 PD34 DI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 PD6 DI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 PD82 DI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pearson (2012) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 PA (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7/7 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fistula: 100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 DI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85 DI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="12" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="12" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Endoscopic series</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pelaez (2008) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 PA (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 endo5 surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73 endo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Irani (2012) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 PA (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pancreatic fistula: 100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 endo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab463251.png" ] ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.A. 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Review article

Disconnected Pancreatic Duct Syndrome

Síndrome del ducto pancreático desconectado

Jose Manuel Ramiaa,

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jose_ramia@hotmail.com

Corresponding author.

, Joan Fabregatb, Manuel Pérez-Mirandac, Joan Figuerasd

a Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, Spain

b Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario de Bellvitge, Barcelona, Spain

c Servicio de Gastroenterología, Hospital Río Hortega, Valladolid, Spain

d Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y Aparato Digestivo, Hospital Josep Trueta, Gerona, Spain

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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; PP&#58; pancreatic prosthesis&#46; PB&#58; biliary prosthesis&#46; CG&#58; cystogastrostomy&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A clinical entity&#44; which had already been referred to in medical literature&#44; consisting of an anatomical situation where there is no continuity of the pancreatic duct between viable pancreatic tissue and the gastrointestinal tract&#44; caused by duct necrosis after severe acute pancreatitis and treated medically&#44; by percutaneous drainage or by necrosectomy&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;8</span></a> was named for the first time by Kozarek et al&#46; as disconnection of the pancreatic duct or disconnected pancreatic duct syndrome in 1991&#46; The isolated viable pancreatic segment continues its exocrine function&#44; causing inflammatory intra or peripancreatic collections or an external pancreatic fistula&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;11</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In addition to acute pancreatitis&#44; other possible aetiologies of DPDS could be chronic pancreatitis&#44; pancreatic trauma&#44; pancreas divisum and other causes&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9&#44;12&#44;13</span></a> Other terms used to define this syndrome are&#58; disconnected pancreatic tail syndrome and disconnected left pancreatic remnant&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">There are no clear epidemiological data on the real incidence of DPDS&#59; approximately 10&#37; and 30&#37; of patients with severe acute pancreatitis could develop DPDS&#46; The incidence of patients diagnosed with DPDS is increasing&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Existing literature is scarce&#59; the terminology is confusing and therapeutic algorithms are not clearly defined&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;7&#44;9</span></a> We have performed a systematic review of the literature on DPDS&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Search</span><p id="par0020" class="elsevierStylePara elsevierViewall">We carried out a search on Pubmed &#40;1966&#8211;2012&#41; for articles in English and Spanish using the terms &#171;disconnected pancreatic duct syndrome&#187; &#40;17&#41; and &#171;disconnected pancreas&#187; &#40;29&#41; and only 15 of the articles we revised were relevant&#46; Given the few citations&#44; the references of these articles were revised for more information on this subject which had not been included in the search terms&#46; Finally&#44; we revised a total of 23 articles&#46; There are no randomised trials&#44; clinical guides or meta-analysis of DPDS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Definition</span><p id="par0025" class="elsevierStylePara elsevierViewall">In acute pancreatitis&#44; pancreatic glandular necrosis has traditionally been considered a determinant of severity&#46; However&#44; in some patients&#44; necrosis of the ductal epithelium is more severe and significant than glandular necrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> DPDS occurs after a variable percentage of pancreatic parenchyma has necrosed&#44; usually in a central location&#44; which causes a ductal lesion that results in the distal remnant becoming disconnected from the pancreatic duct and its exocrine production being unable to drain into the gastrointestinal tract&#46; All of this results in the formation of an intra-abdominal collection or external pancreatic fistula &#40;EPF&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;14</span></a> When there is an EPF there is usually no communication between the fistula and the proximal duct and the fistula is exclusively fed by the distal remnant&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In Howard&#39;s series of 27 patients with DPDS&#44; 70&#37; present with EPF and 30&#37; with intra-abdominal collection&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">DPDS usually occurs after surgical necrosectomy due to acute pancreatitis or walled-off pancreatic necrosis &#40;WOPN&#41; &#40;50&#37;&#8211;75&#37; of patients with DPDS&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> 15&#37;&#8211;25&#37; of patients who have undergone necrosectomy present EPF&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> If these data are real&#44; the question is why do we not find more patients with DPDS&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9</span></a> since it can occur in patients treated with percutaneous drainage as well as in operated patients&#46; It is likely that paucisymptomatic or wrongly diagnosed patients are the reason for the low number of patients diagnosed with DPDS&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The existence of unoperated cases indicates that the cause of DPDS is the ductal damage caused by pancreatitis per se and not surgical or percutaneous intervention&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Diagnosis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Correctly diagnosing DPDS is essential&#44; as its treatment is different from that used in other post-pancreatitis intra or peripancreatic collections&#44; pseudocysts&#44; for example&#44; or post-necrosectomy EPF necrosectomies caused by ductal obstruction which can be resolved with a transpapillary prosthesis placed using ERCP&#44;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;15</span></a> and from so-called partial disruptions of the duct&#44; which should not be considered DPDS as they are not really ductal disconnections&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This difficulty in diagnosis makes it enormously complicated to reach conclusions when results are compared&#44; as it is likely that wrongly diagnosed patients have been included in the series&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The existence on computerised axial tomography &#40;CT&#41; of a thin and small bridge of viable pancreatic tissue&#44; compressed on the lower or posterior side&#44; can suggest the possibility of a misdiagnosis of DPDS as this is showing us a partial disruption&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Fluid collections which compress the gland usually displace the duct that enters them at an oblique&#44; not a straight&#44; angle to the collection wall&#44; as occurs in DPDS&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Methods used for diagnosing DPDS are&#58; CT&#44; nuclear magnetic resonance &#40;MRI&#41; and endoscopic retrograde cholangio-pancreatography &#40;ERCP&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;16</span></a> It has been suggested that ERCP be replaced with nuclear magnetic cholangio resonance &#40;MRC&#41; with secretin stimulation&#44; but the former is more sensitive in demonstrating ductal leakage&#44; although it is more invasive&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6&#44;9&#44;10&#44;13&#44;14&#44;16</span></a> Fistulography can be useful in some cases where there is EPF to differentiate between a terminal and lateral fistula&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The traditional diagnostic criteria for DPDS are&#58; discontinuity of the main pancreatic duct with evidence of viable distal pancreatic tissue and presence of a persistent fluid collection in the imaging methods&#44; or discontinuity of the main pancreatic duct on ERCP and the impossibility of accessing or cannulating the distal duct&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#8211;9&#44;11&#44;14</span></a> A priori and traditionally&#44; when the endoscopist was unable to cross the disconnected area with a guide or drain it was evidence that the duct was completely disconnected and not merely disrupted&#44; although nowadays technical sophistication sometimes makes it possible for the disconnected distal remnant to be cannulated&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9&#44;11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">More specific criteria have been proposed so that we have a DPDS if&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">The CT shows necrosis or a collection in the neck or body of the pancreas of at least 2<span class="elsevierStyleHsp" style=""></span>cm of pancreas and viable distal pancreatic tissue from the area of necrosis&#44; or a pancreatic duct entering the collection at an angle of 90&#176;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Extravasation of contrast material injected into the pancreatic duct in the pancreatography obtained by ERCP&#44; endoscopic or intraoperative ultrasound&#44; or complete section&#47;disconnection of the duct in the distal remnant&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;14</span></a></p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">In a CT scan performed two weeks after the onset of acute pancreatitis&#44; some details suggestive of DPDS could already be recognised&#44; but they were not definite&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The distal pancreatic duct can be seen to be either dilated or otherwise in the different imaging tests&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Necrosis of less than 2<span class="elsevierStyleHsp" style=""></span>cm with no initial ductal lesion can heal without involving the duct but subsequently fibrosis and tissue scarring can cause stenosis of the pancreatic duct which can result in recurrent pancreatitis&#44; although this cannot be referred to as DPDS&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;8</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The most common location of DPDS is the neck of the pancreas&#44; especially in gallstone pancreatitis&#59; this might be due to this area of the pancreas being particularly vascular&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9&#44;10</span></a> Only the dorsal pancreatic artery feeds this area&#44; whereas other regions of the pancreas are vascularised by more than one artery&#46; A disruption of blood flow during pancreatitis causes necrosis and it is possible for DPDS to develop as a result of a ductal lesion&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Although the anatomical disposition with sharp angulation of the duct from upward anterior to transverse posterior can also contribute towards this being the most affected area&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical Features</span><p id="par0080" class="elsevierStylePara elsevierViewall">The existence of a collection or EPF after a necrosectomy or drainage of infected pancreatic necrosis which does not resolve within a reasonable period of time should suggest the possibility of DPDS&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The volume of the fistula dictates the amount of viable pancreatic tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The clinical features are not specific and the following symptoms have been described&#58; abdominal pain&#44; nausea and vomiting&#44; dietary intolerance and weight loss&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Lithiasis is the most frequent aetiology in pancreatitis which causes DPDS&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> 50&#37; of patients with WOPN treated using percutaneous drainage develop DPDS&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;17</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Patients with DPDS are at greater risk of diabetes mellitus&#44; metabolic and nutritional problems due to loss of proteins and electrolytes&#44; and portal hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The following complications associated with DPDS have been described&#58; recurrent pancreatic fluid collections&#44; ascites and pseudoaneurysms&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Treatment</span><p id="par0100" class="elsevierStylePara elsevierViewall">Traditionally&#44; it was thought that DPDS should be treated with surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9</span></a> But there are currently many treatment options &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">DPDS can present as a peripancreatic collection or an EPF&#46; Treatment is different in each case&#46; If the patient presents with a collection which does not increase in size and is asymptomatic&#44; in principle a wait-and-see approach can be taken although symptoms usually develop as the patient is monitored&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> If the collection presents symptoms &#40;pain&#44; fever&#44; recurrent pancreatitis&#41; these must be treated&#44; usually with endoscopic techniques if is feasible &#40;internal drainage &#91;cystogastric or cystoduodenostomies&#93; or a prosthesis up to the ductal remnant&#41;&#46; Puncture by percutaneous drainage must be avoided as this will cause an EFP which will be difficult to resolve&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In the case of an EFP due to DPDS the steps are&#58; medical stabilisation&#44; establishing the anatomy of the ductal disruption and implementing medical&#44; endoscopic or surgical treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;17</span></a> Medical management &#40;nutrition and somatostatin analogues&#41; is slow and has a low success rate&#59; endoscopic techniques are complex and are not always feasible&#59; and surgery is technically difficult&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;15&#44;17</span></a> EFP usually occurs through one of the necrosectomy drains or previous percutaneous drainage&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;10</span></a> There are no guidelines on the optimal treatment for EFP due to DPDS&#46; It usually starts with medical treatment&#44; then endoscopic techniques are used and if these fail&#44; surgery is considered&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">We need to wait for at least six weeks before considering surgical treatment as we postpone surgery until pancreatic inflammation has subsided and the EFP is firmly established&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10&#44;14&#44;18</span></a> Pearson et al&#46; consider surgery in the case of a fistula greater than 100<span class="elsevierStyleHsp" style=""></span>ml&#47;day which persists three months after the onset of DPDS&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">We have summarised the various endoscopic and surgical techniques&#58;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Endoscopic Techniques</span><p id="par0125" class="elsevierStylePara elsevierViewall">Endoscopic techniques are not diagnostic but are now therapeutic for DPDS&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;9</span></a> Furthermore&#44; when they do not completely resolve the DPDS they can serve as a bridge prior to surgery and improve the patient&#39;s local and general conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> The success rate of older series&#44; without clearly defining DPDS&#44; varies between 25&#37; and 37&#37; but has currently improved reaching 61&#37;&#8211;75&#37;&#46; The results are particularly good when there are collections&#44; but less good when there is EPF&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;9&#44;11&#44;17</span></a> Those who defend endoscopic techniques highlight good results&#44; no mortality&#44; low morbidity &#40;25&#37;&#41; and although the relapse rate is close to 50&#37; there is the possibility of repeating the procedure<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;11&#44;17</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The basic initial technique consists of ERCP and placement of a prosthesis but the distal remnant must be drained&#44; which is usually very difficult&#46; We should remember that simple transpapillary drainage is not helpful&#46; As we have mentioned&#44; traditionally it was considered that being unable to cannulate the distal remnant was diagnostic of DPDS&#59; endoscopic techniques having been perfected&#44; meaning that currently&#44; in some patients&#44; it is possible to cannulate the ductal remnant &#40;10&#37;&#8211;25&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;16</span></a> And&#44; as we have mentioned&#44; ductal transpapillary drainage is very effective in lateral fistulas which are not true DPDS but it is not usually possible to resolve the terminal fistulas&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">When distal cannulation has not been feasible&#44; there are other technical options in the literature based on internal drainage by ultrasound endoscopy&#59; i&#46;e&#46;&#44; locating the collection and the duct by means of ultrasound endoscopy and then connecting it with the digestive tract &#40;stomach or duodenum&#41;&#44; placing a prosthesis which joins both&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a> The different options are&#58; performing transgastric pancreatography guided by endoscopic ultrasound to locate the duct and then drain the dilated duct via transgastric route<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;20</span></a>&#59; perform endoscopic ultrasound guided drainage from the fourth duodenal portion<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;19&#44;21</span></a> or use rendezvous techniques combining interventional and endoscopic radiology&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> 20&#37;&#8211;50&#37; of patients who have undergone endoscopic ultrasound drainage develop diabetes mellitus&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In cases treated with internal drainage&#44; there is no consensus on the type of drain that should be used&#46; Permanent drains between the collection and the digestive tract have been used with good results&#44; although there is the danger of migration or infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;17</span></a> Prostheses which are not permanent can become obstructed and cause therapeutic failures in the short or medium term&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Embolisation of the distal pancreatic duct with cyanoacrylate has been performed in very few patients with acceptable results&#58; although it does close the EFP&#44; it does not solve the problem of the disconnected distal remnant&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;14&#44;17&#44;22&#44;23</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Surgical Techniques</span><p id="par0150" class="elsevierStylePara elsevierViewall">Surgery can be considered the definitive solution in the event that endoscopic techniques fail or as a first option&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The surgical treatment of DPDS is criticised principally because of its rate of morbidity &#40;0&#37;&#8211;14&#37;&#41; and mortality &#40;0&#37;&#8211;8&#37;&#41;&#59; its main advantage is its 80&#37; success rate&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;10&#44;15</span></a> Resection techniques &#40;distal pancreatectomy with or without splenectomy&#41; and by-pass techniques &#40;Roux-en-Y fistulojejunostomy&#44; pancreaticojejunostomy or pancreaticogastrostomy&#41; are possible surgical options&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4&#44;5&#44;7&#44;14</span></a> It is recommended that a cholecystectomy be performed if this has not taken place previously&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">By-pass techniques have several advantages&#58; in theory they are simpler &#40;less intraoperative bleeding&#44; less transfusion and less operating time&#41;&#44; they have a lower rate of postoperative complications &#40;6&#37;&#41; and shorter average hospital stay&#44; and they preserve endocrine and exocrine function with a lower rate of postoperative diabetes&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;12&#44;14</span></a> Although in the series of Murage et al&#46;&#44; they present a higher rate of intra-abdominal abscesses than resection techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The average success rate of by-pass techniques as a whole is around 80&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the only series which combines the three by-pass options no differences are observed in terms of results using any one particular technique&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In the series of Pearson et al&#46; of seven fistulojejunostomies &#40;FJ&#41; there was no recurrence of pancreatitis&#44; dilatation of the pancreatic duct&#44; or exocrine insufficiency&#44; but half the patients presented with moderate endocrine insufficiency&#44; which was treated with oral anti-diabetic drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In another short series of FJ&#44; there was a 77&#37;&#8211;100&#37; success rate&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;18</span></a> The authors of these series on FJ underline the need to have a well-formed fibrous tract in order to perform the FJ&#44; it is therefore important to wait a reasonable amount of time before undertaking the operation&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;18</span></a> Murage et al&#46; recommend using a duct-to-mucosa by-pass as they believe this to be better than FJ&#44; although it is sometimes difficult to perform&#44; as it calls for a small pancreatic resection&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The main disadvantage of pancreatic resection is the loss of pancreatic tissue&#44; as this can further compromise exocrine and endocrine function which has often already been damaged&#44; and the difficulty of a resection in an organ with prior pancreatitis&#44; generally increasing the incidence of intraoperative bleeding and morbidity &#40;19&#37;&#41; compared to by-pass techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;10</span></a> Howard et al&#46; recommend resection when there is thrombosis of the splenic vein or left portal hypertension&#44; when malignancy cannot be ruled out and in patients with obstructive pancreatitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a> Murage adds a further indication&#58; a very small ductal remnant &#40;&#60;6<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The success rate of resection techniques is approximately 75&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Recurrence of pancreatic fistula is greater in the pancreatectomy group&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There is mixed data on the rate of re-laparotomy for both types of techniques in the few published series<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 1&#8211;3</a>&#59; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusion</span><p id="par0175" class="elsevierStylePara elsevierViewall">DPDS is a clinical entity that usually occurs after severe acute pancreatitis and which presents with the appearance of a collection or EFP&#46; Correct diagnosis is essential and it should be distinguished&#44; from pancreatic pseudocyst&#44; partial ductal disruption&#44; WOPN and other post pancreatitis symptoms by CT scan and MRC&#46; Traditionally treatment was surgical but now it can be endoscopic&#44; using either ERCP or&#44; usually&#44; internal endoscopic ultrasound guided drainage&#46; Endoscopic techniques present low morbimortality but are less successful in the long term than surgical techniques&#46; By-pass or resection surgery is more effective but has greater morbimortality&#46; There are no internationally- agreed therapeutic algorithms but it is increasingly more common to use endoscopic techniques first and if they fail&#44; consider surgery&#46; DPDS is another disease where it has been demonstrated that multidisciplinary collaboration among radiologists&#44; gastroenterologists and surgeons is fundamental for the care of patients with complex pancreatic disease&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of Interests</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "identificador" => "xres314995"
          "titulo" => "Abstract"
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        2 => array:2 [
          "identificador" => "xres314994"
          "titulo" => "Resumen"
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          "identificador" => "xpalclavsec297735"
          "titulo" => "Palabras clave"
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          "identificador" => "sec0005"
          "titulo" => "Search"
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          "identificador" => "sec0010"
          "titulo" => "Definition"
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          "identificador" => "sec0015"
          "titulo" => "Diagnosis"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Clinical Features"
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        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Treatment"
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            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Endoscopic Techniques"
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Surgical Techniques"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Conclusion"
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        10 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflict of Interests"
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        11 => array:1 [
          "titulo" => "References"
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    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-02-06"
    "fechaAceptado" => "2013-02-19"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec297734"
          "palabras" => array:5 [
            0 => "Disconnected pancreatic duct syndrome"
            1 => "Pancreas"
            2 => "Surgery"
            3 => "Pancreatitis"
            4 => "Review"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec297735"
          "palabras" => array:5 [
            0 => "S&#237;ndrome del ducto desconectado"
            1 => "P&#225;ncreas"
            2 => "Cirug&#237;a"
            3 => "Pancreatitis"
            4 => "Revisi&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Disconnected pancreatic duct syndrome &#40;DPDS&#41; is characterised by disruption of the main pancreatic duct with a loss of continuity between the pancreatic duct and the gastrointestinal tract caused by ductal necrosis after severe acute necrotising pancreatitis treated medically&#44; by percutaneous drainage&#44; or necrosectomy&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">There are no clear epidemiological data on the real incidence of DPDS&#59; approximately 10&#37;&#8211;30&#37; of patients with severe acute pancreatitis could develop DPDS&#46; The existing literature is scarce&#44; the terminology is confusing and therapeutic algorithms are not clearly defined&#46; Both endoscopic management and surgical management have been described&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We have performed a systematic review of the literature on DPDS&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La desconexi&#243;n del ducto pancre&#225;tico&#44; o s&#237;ndrome del ducto pancre&#225;tico desconectado &#40;SDPD&#41;&#44; es una entidad cl&#237;nica que consiste en la existencia de una situaci&#243;n anat&#243;mica en la que hay ausencia de la continuidad del conducto pancre&#225;tico entre el tejido pancre&#225;tico viable y el tracto gastrointestinal&#44; causada por necrosis ductal tras pancreatitis aguda grave tratada mediante necrosectom&#237;a&#44; drenaje percut&#225;neo o m&#233;dicamente&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">No hay datos epidemiol&#243;gicos claros sobre la incidencia real de SDPD&#46; Se ha postulado que entre un 10 y un 30&#37; de los pacientes con pancreatitis aguda grave desarrollan un SDPD&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La literatura existente sobre este tema es escasa&#44; los t&#233;rminos empleados son confusos y los algoritmos terap&#233;uticos son poco claros&#46; Las opciones terap&#233;uticas son endosc&#243;picas y quir&#250;rgicas&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Hemos efectuado una revisi&#243;n sistem&#225;tica de la literatura sobre SDPD&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ramia JM&#44; Fabregat J&#44; P&#233;rez-Miranda M&#44; Figueras J&#46; S&#237;ndrome del ducto pancre&#225;tico desconectado&#46; Cir Esp&#46; 2014&#59;92&#58;4&#8211;10&#46;</p>"
      ]
    ]
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        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">SDPD&#58;ERCP&#58;biliary tract dilatation and leak in pancreatic body&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
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            "imagen" => "gr2.jpeg"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patient <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; PP&#58; pancreatic prosthesis&#46; PB&#58; biliary prosthesis&#46; CG&#58; cystogastrostomy&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1107
            "Ancho" => 1500
            "Tamanyo" => 208500
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">&#40;A and B&#41; Endoscopic retrograde pancreatography &#40;ERCP&#41;&#58; &#40;A&#41; Duct of Wirsung with complete transection in yuxta-cephalic body with the head of the duct opacified&#44; and no fill in body and tail&#46; &#40;B&#41; Endoscopic catheter tip &#40;sphincterometer&#41; in the transection&#46; Opacification of residual collection and Wirsung duct in the tail via percutaneous catheter&#46; &#40;C and D&#41; Opacification of residual collection and Wirsung duct in the tail via the percutaneous catheter&#46; &#40;C and D&#41; Endosonographic pancreatography &#40;ESCP&#41; via transgastric puncture&#46; &#40;C&#41; Injection of contrast through a dilator introduced using transgastric Seldinger up to the duct of Wirsung in the tail&#46; &#40;D&#41; Plastic pancreatogastric prosthesis&#44; on guide &#40;pancreatico-gastrostomy&#41;&#46;</p>"
        ]
      ]
      3 => array:6 [
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">DI&#58; internal bypass&#59; Endo&#58; endoscopy&#59; ND&#58; not available&#59; PA&#58; acute pancreatitis&#59; PD&#58; distal pancreatectomy&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Gender &#40;&#37; males&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Aetiology&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Previous necrosectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Presentation of DLPR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Type of surgery&#47;endo&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Morb&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Mort&#46; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Success &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Follow-up &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="12" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Surgical series</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Howard &#40;2001&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 PA &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pseudocyst&#58; 70&#37;Pancreatic fistula&#58; 30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 PD13 DI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NDND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 PD7 DI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93 PD100 DI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PD&#58; 19DI&#58;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Murage &#40;2010&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 PA &#40;73&#41;17 PC &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#47;59 &#40;71&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pseudocyst&#58; 53&#37;Pancreatic fistula&#58; 34&#37;Pancr&#46; obstructive&#58; 13&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 PD34 DI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 PD6 DI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74 PD82 DI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pearson &#40;2012&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 PA &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#47;7 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fistula&#58; 100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 DI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">85 DI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="12" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="12" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Endoscopic series</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pelaez &#40;2008&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 PA &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 endo5 surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73 endo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Irani &#40;2012&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 PA &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pancreatic fistula&#58; 100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 endo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46;A&#46; Kozarek"
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                            2 => "D&#46;J&#46; Patterson"
                            3 => "P&#46;C&#46; Freeny"
                            4 => "J&#46;A&#46; Ryan"
                            5 => "L&#46;W&#46; Traverso"
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                        "paginaFinal" => "1370"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2013381"
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                    0 => array:2 [
                      "titulo" => "Clinical framework to guide operative decision making in disconnected left pancreatic disruption &#40;DLPR&#41; following acute or chronic pancreatitis"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K&#46;P&#46; Murage"
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                            3 => "A&#46; Nakeeb"
                            4 => "C&#46; Ocampo"
                            5 => "K&#46; Sandrasegaran"
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                    0 => array:2 [
                      "doi" => "10.1016/j.surg.2010.07.039"
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                0 => array:2 [
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                      "titulo" => "Endoscopic placement of permanent indwelling transmural stents in disconnected pancreatic duct syndrome&#58; does benefit outweigh the risks"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "S&#46; Varadarajulu"
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                      "titulo" => "Lehman GA Roux-en-Y internal drainage is the best surgical option to treat patients with disconnected duct syndrome after severe acute pancreatitis"
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Article information

ISSN: 21735077
Original language: English

DOI:10.1016/j.cireng.2013.02.009

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Year/Month	Html	Pdf	Total

2024 October	145	8	153
2024 September	274	11	285
2024 August	239	19	258
2024 July	308	20	328
2024 June	239	7	246
2024 May	238	7	245
2024 April	165	24	189
2024 March	222	18	240
2024 February	245	32	277
2024 January	350	17	367
2023 December	272	32	304
2023 November	350	10	360
2023 October	495	3	498
2023 September	192	10	202
2023 August	133	4	137
2023 July	158	11	169
2023 June	111	9	120
2023 May	181	12	193
2023 April	92	8	100
2023 March	98	6	104
2023 February	75	14	89
2023 January	99	14	113
2022 December	52	14	66
2022 November	83	24	107
2022 October	74	8	82
2022 September	58	11	69
2022 August	76	14	90
2022 July	34	10	44
2022 June	72	13	85
2022 May	73	10	83
2022 April	65	8	73
2022 March	88	12	100
2022 February	79	8	87
2022 January	107	17	124
2021 December	77	22	99
2021 November	74	20	94
2021 October	87	22	109
2021 September	98	20	118
2021 August	89	16	105
2021 July	55	15	70
2021 June	52	13	65
2021 May	80	21	101
2021 April	220	27	247
2021 March	111	26	137
2021 February	55	17	72
2021 January	74	21	95
2020 December	90	16	106
2020 November	106	17	123
2020 October	48	13	61
2020 September	81	30	111
2020 August	102	38	140
2020 July	60	13	73
2020 June	58	14	72
2020 May	91	15	106
2020 April	61	16	77
2020 March	90	20	110
2020 February	65	17	82
2020 January	79	24	103
2019 December	71	20	91
2019 November	64	7	71
2019 October	63	12	75
2019 September	63	13	76
2019 August	43	6	49
2019 July	61	20	81
2019 June	143	13	156
2019 May	271	22	293
2019 April	88	9	97
2019 March	42	10	52
2019 February	46	5	51
2019 January	32	1	33
2018 December	44	10	54
2018 November	55	12	67
2018 October	42	5	47
2018 September	38	6	44
2018 August	41	12	53
2018 July	32	1	33
2018 June	15	1	16
2018 May	22	2	24
2018 April	61	1	62
2018 March	19	1	20
2018 February	22	1	23
2018 January	26	2	28
2017 December	12	0	12
2017 November	23	1	24
2017 October	21	1	22
2017 September	39	3	42
2017 August	23	4	27
2017 July	30	1	31
2017 June	50	2	52
2017 May	40	6	46
2017 April	39	8	47
2017 March	32	13	45
2017 February	41	2	43
2017 January	48	3	51
2016 December	47	8	55
2016 November	46	5	51
2016 October	92	4	96
2016 September	132	14	146
2016 August	48	9	57
2016 July	28	2	30
2016 June	35	15	50
2016 May	52	17	69
2016 April	45	15	60
2016 March	40	19	59
2016 February	24	16	40
2016 January	31	13	44
2015 December	35	17	52
2015 November	24	4	28
2015 October	41	13	54
2015 September	44	9	53
2015 August	44	19	63
2015 July	54	11	65
2015 June	25	13	38
2015 May	50	13	63
2015 April	46	9	55
2015 March	29	6	35
2015 February	16	2	18
2015 January	46	11	57
2014 December	77	24	101
2014 November	45	12	57
2014 October	38	8	46
2014 September	22	4	26
2014 August	36	12	48
2014 July	42	11	53
2014 June	20	10	30
2014 May	35	8	43
2014 April	13	20	33

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