S5322 Traumatic Disconnected Pancreatic Duct: Delayed Diagnosis Requiring Multidisciplinary Approach

Introduction: Disconnected pancreatic duct syndrome (DPDS) is an often-overlooked rare complication of necrotizing pancreatitis causing a disconnect between functional upstream pancreatic parenchyma and the duodenum. The disconnected upstream pancreas, being functional, continues to secrete pancreatic fluid which can lead to recurrent fluid collections. We present a case of DPDS stemming from a trauma requiring a multidisciplinary approach for effective treatment. Case Description: She is a 35-year-old woman with a history of a prior MVA with multiple operations with original course complicated by resulting recurrent peripancreatic fluid collections and walled off necrosis. She had cystgastrostomy stent placement which failed; the stent was removed. She presented locally with epigastric pain and inability to tolerate oral intake. CT abdomen/pelvis showed a 67 × 95 × 72 mm peripancreatic pseudocyst exerting mass effect on the stomach. She was treated with fluids, ceftriaxone, and referred for further care. Nasogastric and nasojejunal tubes were placed for feeding and decompression. EUS revealed 70 × 70 mm pseudocyst in the body of the pancreas which was aspirated and showed amylase 40,520 glucose 61. Endoscopic retrograde cholangiopancreatography (ERCP) revealed incomplete pancreas divisum with complete disconnection in the body of the pancreas. She underwent open pancreatic debridement with extensive lysis of adhesions, central pancreatectomy with Roux-en-Y pancreatojejunostomy. Her diet was slowly advanced, and tube feeding was able to be discontinued. Discussion: The presentation of DPDS can vary based on etiology of the disconnection, exact location of the disruption, and the volume of the pancreatic fluid secretions. This often causes delay in diagnosis which increases morbidity, mortality, and the cost of treatment. ERCP is the gold standard to identify pancreatic duct disruption, with endoscopic ultrasound being useful to assess communication with the main duct and promote early recognition of DPDS. Chong et al. reviewed treatment strategies with endoscopic transmural drainage superior to transpapillary drainage. Endoscopic and surgical interventions have similar success rates. In our patient, due to the location of the disconnection and with multidisciplinary discussion, optimal treatment was successful with combined endoscopic and surgical evaluation and treatment.