An Important But Overlooked Complication of Severe Acute Pancreatitis
Kumaresan Sandrasegaran, MD ; Mark Tann, MD ; S. Gregory Jennings, MD ; Dean D. Maglinte, MD ; Sanjit D. Peter, MD ; Stuart Sherman, MD ; Thomas J. Howard, MD
1 From the Departments of Radiology (K.S., M.T., S.G.J., D.D.M.), Surgery (S.D.P., T.J.H.), and Medicine (S.S.), Indiana University School of Medicine, 550 N University Blvd, Suite UH 0279, Indianapolis, IN 46202. Recipient of a Certificate of Merit award for an education exhibit at the 2005 RSNA Annual Meeting. Received September 5, 2006; revision requested October 30 and received December 18; accepted December 19. K.S. receives research support from Koninklijke Philips Electronics NV, Cleveland, Ohio; D.D.M. is a consultant for Cook, Bloomington, Ind, and E-Z-Em, Westburg, NY; S.S. is a consultant for Repligen, Waltham, Mass; all other authors have no financial relationships to disclose.
In patients with severe acute pancreatitis, the percentage of necrosis of pancreatic glandular parenchyma is an important predictor of prognosis. However, little attention has been paid to necrosis of ductal epithelium, which may result in disconnection of the main pancreatic duct. In pancreatic duct disconnection, a viable segment of the pancreatic body or tail is isolated from the gastrointestinal tract; the result is a persistent end fistula, that is, an uncontrolled leak of pancreatic secretions into peripancreatic spaces without communication to the gastrointestinal tract. The authors present their experience with clinical and radiologic follow-up of 85 patients with necrotic pancreatitis who either did (n = 46) or did not (n = 39) have pancreatic duct disconnection at surgery. Confident preoperative diagnosis of a disconnected duct requires both imaging tests (computed tomography or magnetic resonance imaging) and pancreatography. However, not all peripancreatic collections signify ductal disconnection, and imaging has poor accuracy in differentiation between pancreatic and peripancreatic necrosis. Early recognition of disconnected pancreatic duct obviates unnecessary and potentially harmful drainage procedures.