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In a subset of patients with acute necrotizing pancreatitis, segmental necrosis affecting the main pancreatic duct may result in a discontinuity between the left-sided pancreas and the duodenum. Such an interruption in the setting of a viable upstream portion of the gland can give rise to the disconnected pancreatic duct syndrome (DPDS). By maintaining its secretory function, the disconnected segment may lead to persistent external pancreatic fistulae, recurrent pancreatic fluid collections, and/or obstructive recurrent acute or chronic pancreatitis of the isolated parenchyma. There are currently no universally accepted guidelines for the diagnosis or treatment of DPDS, and because the condition is underrecognized, the diagnosis is often delayed. DPDS is associated with a prolonged disease course and poses a burden on patients' quality of life as well as high health care resource utilization. The aim of our review is to summarize current knowledge, discuss diagnostic approaches, outline management options, and raise awareness of this challenging complication of necrotizing pancreatitis.

Abstract Background Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aimed to review the definitions, clinical presentation, intervention, and outcomes for DPDS. Methods The PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites. Results Thirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.3%, 936/982), followed by chronic pancreatitis (3.1%, 30/982). DPDS commonly presented with PFC (83.2%, 948/1140) and EPF (13.4%, 153/1140). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI 81.0–95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7–77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6–90.5) and 87.4% (95%-CI 81.2–91.8), respectively (P = 0.389). Conclusions Endoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research.

Background: Disconnected pancreatic duct syndrome (DPDS) is a complication of acute necrotizing pancreatitis in the neck and body of the pancreas often manifesting as persistent pancreatic fluid collection (PFC) or external pancreatic fistula (EPF). This systematic review and pairwise meta-analysis aimed to review the definitions, clinical presentation, intervention, and outcomes for DPDS.Methods: The PubMed, EMBASE, MEDLINE, and SCOPUS databases were systematically searched until February 2020 using the PRISMA framework. A meta-analysis was performed to assess the success rates of endoscopic and surgical interventions for the treatment of DPDS. Success of DPDS treatment was defined as long-term resolution of symptoms without recurrence of PFC, EPF, or pancreatic ascites.Results: Thirty studies were included in the quantitative analysis comprising 1355 patients. Acute pancreatitis was the most common etiology (95.3%, 936/982), followed by chronic pancreatitis (3.1%, 30/982). DPDS commonly presented with PFC (83.2%, 948/1140) and EPF (13.4%, 153/1140). There was significant heterogeneity in the definition of DPDS in the literature. Weighted success rate of endoscopic transmural drainage (90.6%, 95%-CI 81.0-95.6%) was significantly higher than transpapillary drainage (58.5%, 95%-CI 36.7-77.4). Pairwise meta-analysis showed comparable success rates between endoscopic and surgical intervention, which were 82% (weighted 95%-CI 68.6-90.5) and 87.4% (95%-CI 81.2-91.8), respectively (P = 0.389).Conclusions: Endoscopic transmural drainage was superior to transpapillary drainage for the management of DPDS. Endoscopic and surgical interventions had comparable success rates. The significant variability in the definitions and treatment strategies for DPDS warrant standardisation for further research. [ABSTRACT FROM AUTHOR]

We present a case report of a 61 years old male monitored for post-traumatic acute pancreatitis, with pancreatic duct disruption and subsequent pseudocyst formation in the pancreatic tail. Because of gradual progression of this pseudocyst's size, the patient was indicated for endoscopic ultrasound-guided pseudocystogastrostomy with 3 double pig-tail stents. In the meantime, the patient's condition was complicated by an infection of the pseudocyst, which was managed using antibiotic therapy. During the next year, the patient had to be repeatedly admitted at the gastroenterology department for pancreatic duct drainage using ERCP (5x). During this time, a pancreatic stent was introduced and repeatedly had to be replaced. Repeated check-ups were performed using abdominal ultrasound and CT (computed tomography -- 6x) and endosonography of the pancreas, including fine-needle aspiration (EUS-FNA -- 2x). Less than two years after the injury, multiple liver metastases were found using CT, the primary tumour was not detected. In a follow-up endosonography, a hypoechogenic mass was found in the pancreatic body, with evidence of malignant cells according to the collected cytology. After the final diagnosis of pancreatic adenocarcinoma, the patient has died, with cause of death being the spreading of the disease. [ABSTRACT FROM AUTHOR]

Introduction: Asymptomatic walled-off pancreatic necrosis (WOPN) should be treated conservatively, irrespective of the extent and size of the necrosis. The aim of this study was to evaluate the efficacy and safety of a strategy involving the observation of patients with asymptomatic WOPN over a long period of time.Material and Methods: This study involved the retrospective analysis of 368 patients hospitalized in our department between 2010 and 2016, due to acute pancreatitis and its consequences in the form of pancreatic and peripancreatic fluid collection.Results: Walled-off pancreatic necrosis was identified in 168/368 (46%) patients. 124/168 (74%) patients with WOPN required interventional treatment due to clinical symptoms arising from the presence of the WOPN. Asymptomatic WOPN was identified in 44/168 (26%) patients. The mean observation time of patients with asymptomatic WOPN was 417.02 days (range: 47-1149 days). Only 1 out of the 44 patients (2%) failed to complete the follow-up. Complete regression of WOPN occurred in 30/44 (68%) patients. The presence of symptoms related to WOPN were identified in 13/44 (30%) patients during the observation. The most frequent indication for interventional treatment of WOPN was infection of the pancreatic necrosis, which was identified in 6/13 patients (46%). Altogether, 137/168 (82%) patients with WOPN required interventional treatment.Conclusions: The majority of patients with WOPN required interventional treatment. This study provided evidence to support the view that careful observation of patients with asymptomatic WOPN is an efficient and safe treatment strategy. Long-term observation of such patients showed that most will experience spontaneous regression of asymptomatic WOPN without any other form of interventional treatment. [ABSTRACT FROM AUTHOR]

Background: The place of endoscopic techniques in the treatment of main pancreatic duct (MPD) disruption arising in the course of acute necrotizing pancreatitis (ANP) remains unclear. The aim of this study was to describe the findings of endoscopic retrograde pancreatography (ERP) in patients with walled-off necrosis (WON). It was attempted to evaluate the role of endoscopic treatment of pancreatic duct disruption in patients with WON.Methods: The retrospective analysis of results and complications with particular emphasis to all ERP procedures in the group of 226 patients was conducted, which underwent endoscopic treatment of symptomatic WON between years 2001 and 2016 in the Department of Gastroenterology and Hepatology of Medical University of Gdańsk.Results: ERP was performed in 204/226 (90.27%) patients. Partial and complete disruption of the MPD were identified in 103 (50.49%) and 63 (30.89%) out of 204 patients, respectively. Endoscopic treatment was used in all 166 patients with MPD disruption. The success of endoscopic treatment of MPD disruption was achieved in 138/161 (85.71%) patients with WON. The therapeutic success of WON endotherapy was achieved in 214/226 (94.69%) patients. The mean follow-up duration was 56 (SD = 37.06) [range 14-158] months. Long-term success of treatment of WON was achieved in 182/226 (80.53%) patients.Conclusions: MPD disruption occurs in the majority of patients with WON. Partial disruption of the MPD is more frequent than complete disruption of the duct. This study conducted on a large group of patients demonstrated that prosthesis insertion into the MPD in patients with disruption of the MPD in the course of ANP is one of the key elements in endoscopic treatment of WON. Passive transpapillary drainage is an effective method of treating MPD disruptions, which improves long-term outcomes of endoscopic treatment in patients with WON. [ABSTRACT FROM AUTHOR]

Introduction: The traditional method of managing Pancreatic Ascites (PA) complicating Chronic Pancreatitis (CP) was with initial conservative treatment which was associated with increased morbidity and mortality. Aim: To describe about the new treatment protocol which lays emphasis on primary early surgical intervention for PA complicating advanced CP cases based on the pathological morphology of the disease instead of an initial trial of conservative treatment. Materials and Methods: This was a prospective observational study of 15 cases of CP with PA managed over a three year period. The approach was guided by the pathological morphology defined by a CECT abdomen and/or Magnetic Resonance Cholangiopancreatography (MRCP). Of the observed 15 cases, imaging showed a dilated Main Pancreatic Duct (MPD) 5-10 mm in 11 cases, ductal disruption in 4/11 cases and pseudocyst in 8/11 cases. These 11 cases underwent primary early direct surgery. Surgery was tailored to the individual case with a combination of internal ductal/pseudocyst drainage and/or distal resection. Resolution of PA and relief of symptoms were the primary outcome measures. Recurrence of PA at one year follow up after surgery was the secondary outcome measure. Results: Resolution of PA and relief of symptoms occurred in all patients in the primary surgery group. The mean duration of hospital stay was 16 days in the primary surgery group with a range of nine to 23 days with no mortality and no disease recurrence after one year of follow up. Conclusion: Primary early direct surgery guided by the MPD morphology (duct diameter >5 mm) in selected patients with CP and PA leads to faster recovery of the patient and it takes care of the primary pathology too.

Disconnected pancreatic duct (DPD) is common after acute necrotizing pancreatitis (ANP). Its clinical implications vary according to the course of disease. In the early phase of ANP, parenchymal necrosis along with disruption of pancreatic duct cause acute necrotic collection that evolves into walled-off necrosis (WON). In the later phase, DPD becomes evident as confirmed by magnetic resonance cholangiopancreatography. Clinical manifestations of DPD can vary from being asymptomatic, recurrent pain, recurrent pancreatic fluid collection (PFC), obstructive pancreatitis, or external pancreatic fistula (EPF). Few patients develop new-onset diabetes. Long-term indwelling plastic stents have been proposed to prevent the recurrent PFC., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: The traditional method of managing Pancreatic Ascites (PA) complicating Chronic Pancreatitis (CP) was with initial conservative treatment which was associated with increased morbidity and mortality. Aim: To describe about the new treatment protocol which lays emphasis on primary early surgical intervention for PA complicating advanced CP cases based on the pathological morphology of the disease instead of an initial trial of conservative treatment. Materials and Methods: This was a prospective observational study of 15 cases of CP with PA managed over a three year period. The approach was guided by the pathological morphology defined by a CECT abdomen and/or Magnetic Resonance Cholangiopancreatography (MRCP). Of the observed 15 cases, imaging showed a dilated Main Pancreatic Duct (MPD) 5-10 mm in 11 cases, ductal disruption in 4/11 cases and pseudocyst in 8/11 cases. These 11 cases underwent primary early direct surgery. Surgery was tailored to the individual case with a combination of internal ductal/pseudocyst drainage and/or distal resection. Resolution of PA and relief of symptoms were the primary outcome measures. Recurrence of PA at one year follow up after surgery was the secondary outcome measure. Results: Resolution of PA and relief of symptoms occurred in all patients in the primary surgery group. The mean duration of hospital stay was 16 days in the primary surgery group with a range of nine to 23 days with no mortality and no disease recurrence after one year of follow up. Conclusion: Primary early direct surgery guided by the MPD morphology (duct diameter >5 mm) in selected patients with CP and PA leads to faster recovery of the patient and it takes care of the primary pathology too. [ABSTRACT FROM AUTHOR]

Background: A disconnected distal pancreas (DDP) remnant is a morbid sequela of necrotizing pancreatitis. Definitive surgical management can be accomplished by either fistulojejunostomy (FJ) or distal pancreatectomy (DP). It is unclear which operative approach is superior with regard to short- and long-term outcomes.Methods: Between 2002 and 2014, patients undergoing either FJ or DP for DDP were retrospectively identified at a center specializing in pancreatic diseases. Patient demographics, perioperative, and postoperative variables were evaluated.Results: Forty-two patients with DDP secondary to necrotizing pancreatitis underwent either a FJ (n = 21) or DP (n = 21). Between the two cohorts, there were no significant differences in overall lengths of stay, pancreatic leak rates, or readmission rates (all p > 0.05). DP was associated with higher estimated blood loss, increased transfusion requirements, and worsening endocrine function (all p < 0.05). At a median follow-up of 18 months, four patients that underwent a FJ developed a recurrent fluid collection requiring re-intervention. Overall, FJ was successful in 80% of patients as compared to a 95% success rate for DP (p = 0.15).Conclusions: Although DP was associated with higher intraoperative blood loss, increased transfusion requirements, and worsening of preoperative diabetes, this procedure provides superior long-term resolution of a DDP when compared to FJ. [ABSTRACT FROM AUTHOR]

A 66-year-old man was admitted for severe acute alcoholic pancreatitis with infected pancreatic necrosis (IPN). Abdominal computed tomography revealed an inflamed pancreatic head, a dilated main pancreatic duct (MPD), and a large cavity with heterogeneous fluid containing gas adjacent to the pancreatic head, and extending to the pelvis. The cavity was drained percutaneously near the pancreatic head on admission; another tube was inserted into the pelvic cavity on hospital day 3. The drained fluid contained pus with high amylase concentration. Nasopancreatic drainage tube placement was unsuccessfully attempted on hospital day 9. On hospital day 23, percutaneous puncture of the MPD and placement of a pancreatic duct drainage tube was performed. Pancreatography revealed major extravasation from the pancreatic head. The IPN cavity receded; the percutaneous IPN drainage tube was removed on hospital day 58. On hospital day 83, the pancreatic drainage was changed to a transpapillary pancreatic stent, and the patient was discharged. Measuring the amylase concentration of peripancreatic fluid collections can aid in the diagnosis of pancreatic duct disruption; moreover, dual percutaneous necrotic cavity drainage plus pancreatic duct drainage may be essential for treating IPN. If transpapillary drainage tube placement is difficult, percutaneous pancreatic duct drainage may be feasible. [ABSTRACT FROM AUTHOR]

A 44-year-old man presenting to our hospital emergency room with abdominal pain was hospitalized for hyperlipidemic acute pancreatitis. A pig-tail catheter was placed percutaneously to drain an abscess on day 22. Although the abscess improved gradually and good clinical progress was seen, pancreatic duct disruption was strongly suspected and endoscopic retrograde cholangiopancreatography was performed on day 90. An endoscopic nasopancreatic drainage tube was placed, but even with concurrent use of a somatostatin analogue, treatment was ineffective. Surgical treatment was elected, but was subsequently postponed as the abscess culture was positive for extended-spectrum β-lactamase-producing Escherichia coli and methicillin-resistant Staphylococcus aureus. Drainage tubography showed a small fistula of the colon at the splenic flexure on day 140. Colonoscopy was performed on day 148. After indigo carmine had been injected, a fistula into the splenic flexure of the colon showed blue staining. The over-the-scope clip (OTSC) system was used to seal the fistula and complete closure was shown. A liquid diet was started on day 159 and was smoothly upgraded to a full diet. Following removal of the pancreatic stent on day 180, drainage volume immediately decreased and the percutaneous drain was removed. On day 189, computed tomography showed no exacerbation of the abscess and the patient was discharged on day 194. This case of colonic fistula caused by severe acute pancreatitis was successfully treated using the OTSC system, avoiding the need for an open procedure.

Background The development of pancreatic fistula (PF) associated with pancreatic necrosis is of great concern in the management of severe acute pancreatitis (SAP). We expected that early recognition and intervention of PF combined with percutaneous catheter drainage (PCD) for pancreatic infection may improve SAP outcomes. Methods Fifteen consecutive patients with SAP were enrolled. Whenever feasible, fine-needle aspiration for fluid collection was performed to determine infection and amylase concentration. For infection and PF with amylase-rich fluid, PCD and transpapillary endotherapy (preferably naso-pancreatic drainage) were carried out as soon as possible. PCD was intensively managed by irrigating the sized-up and multiple large bore catheters. Results Infected fluid collection and PF were both detected in 13 (86.7%) patients. Pancreatic duct (PD) disruption (n = 6) and organ failure (n = 5) occurred exclusively in patients with amylase-rich collection ≥10,000 U/L. The median timing of PCD and endotherapy was 15.5 and 16.5 days, respectively. No serious complications or mortality resulted from intervention procedures other than stent occlusion in one (6.7%) patient. Surgical intervention due to uncontrollable infection and visceral organ injury was avoided. Fistula closure was achieved in 12 (92.3%) of 13 PF patients with a median duration of 45 days. Disease-related mortality occurred in one (6.7%) patient. Conclusion Amylase-rich fluid collection ≥10,000 U/L may be an indication for further endoscopic investigation of PD disruption. Early dual drainage combining pancreatic endotherapy and PCD is feasible and safe, and may improve treatment outcome. [ABSTRACT FROM AUTHOR]

Introduction Pancreatic injury is uncommon and the management remains controversial. The integrity of the main pancreatic duct is considered the most important determinant for prognosis. Case presentation A 19-year-old Greek man was referred to our tertiary referral centre due to blunt abdominal trauma and an associated grade III pancreatic injury. He was haemodynamically stable and his initial treatment was conservative. Due to deterioration in his clinical symptomatology he underwent an endoscopy 20 days postinjury, where a stent was placed in the proximal pancreatic duct remnant and a bulging fluid collection of the lesser sac was drained transgastrically. He made an uneventful recovery and remains well 7 months postinjury, but a stricture with upstream dilatation of his main pancreatic duct has developed. Conclusions The clinical status of the patient rather than the grade of pancreatic injury should be the principal determinant to guide treatment. Endoscopic stenting and drainage is an attractive minimally invasive procedure and it may obviate the need for surgery. However, further investigation is required regarding the safety and outcome. [ABSTRACT FROM AUTHOR]

In a subset of patients with acute necrotizing pancreatitis, segmental necrosis affecting the main pancreatic duct may result in a discontinuity between the left-sided pancreas and the duodenum. Such an interruption in the setting of a viable upstream portion of the gland can give rise to the disconnected pancreatic duct syndrome (DPDS). By maintaining its secretory function, the disconnected segment may lead to persistent external pancreatic fistulae, recurrent pancreatic fluid collections, and/or obstructive recurrent acute or chronic pancreatitis of the isolated parenchyma. There are currently no universally accepted guidelines for the diagnosis or treatment of DPDS, and because the condition is underrecognized, the diagnosis is often delayed. DPDS is associated with a prolonged disease course and poses a burden on patients' quality of life as well as high health care resource utilization. The aim of our review is to summarize current knowledge, discuss diagnostic approaches, outline management options, and raise awareness of this challenging complication of necrotizing pancreatitis., Competing Interests: All authors declare no conflicts of interest in relation to this article., (© 2022 The Authors.)

Abstract: Background: Few studies have described the role of multimodality therapy and the complexity of endoscopic management of pancreatic duct disruption. Our study aim was to analyse and confirm factors associated with the resolution of pancreatic duct disruption. Methods: Over 6 years, retrospective data on patients with pancreatic duct disruption managed endoscopically were retrieved. Success was defined as resolution of the pancreatic duct disruption at 12 months. Logistic regression analysis was performed to determine factors associated with resolution. Results: 113 patients (78 male) with a mean age 51.3 year were included. Resolution of the pancreatic duct leak occurred in 80 cases (70.2%). 72 cases received transpapillary pancreatic duct stents, with 51 demonstrating resolution of pancreatic duct leak (71%) cystenterostomy was performed in 68 patients with 51 resolved (75%). In partial duct disruptions, pancreatic duct stenting combined with endoscopic drainage of fluid collections resulted in an increased rate of resolution (80%) compared to complete disruptions treated in a similar manner (57%). In complete pancreatic ductal disruptions, transpapillary pancreatic duct stenting had no additional benefit (9/17, 52.9%) compared to cystenterostomy or percutaneous drainage alone (24/34, 70.6%; P =0.61). Conclusion: Pancreatic duct disruptions require multimodality treatment, addressing not only the integrity of the pancreatic duct but also any fluid collections associated. Partial ductal disruption should be managed by a bridging stent. [Copyright &y& Elsevier]

Background and Aim: The role of pancreatic duct (PD) stenting in patients undergoing endoscopic transmural drainage of peripancreatic fluid collection (PFC) remains unclear. The objective of this study is to evaluate the effect of PD stenting on treatment success in patients undergoing endoscopic transmural drainage of PFC. Methods: This is a retrospective follow-up study of all patients who underwent endoscopic and endoscopic ultrasonography-guided transmural drainage of PFC during a 5-year period. Double-pigtail stents were deployed in all patients; in addition, nasocystic catheters were deployed in those with abscess/necrosis. An endoscopic retrograde cholangiopancreatogram was attempted whenever feasible in all patients, and pancreatic stents were placed when the duct disruption could be bridged. Success was defined as an improvement in symptoms and resolution of PFC upon follow-up computed tomography at 8 weeks. Results: Of the 110 patients who underwent PFC drainage, 40 (36%) underwent simultaneous PD stenting. Treatment was successful in 95 of the 110 patients (86%). The PFC types were: pseudocyst (62%), necrosis (20%), and abscess (18%). The median duration of follow up was 9.9 months. Those who underwent PD stenting were significantly more likely to have treatment success than those who did not undergo PD stenting (97.5% vs 80%; risk ratio [RR]crude = 1.48, P = 0.01). In the multivariable analysis, this association remained significant (RRadjusted = 1.14, 95% confidence interval: 1.01–1.29, P = 0.036), even after adjusting for the etiology of pancreatitis, type and location of PFC, luminal compression at endoscopy, enteral nutrition, white blood cell count, and number of endoscopic interventions. Conclusions: Transpapillary PD stenting improves treatment outcomes in patients undergoing endoscopic transmural drainage of PFC. [ABSTRACT FROM AUTHOR]

In last thirty years we have been observing significant development of an endoscopic treatment of pancreatic fluid collections, including transmural drainage of walled-off pancreatic necrosis. Simultaneously, the use of endotherapy in treatment of main pancreatic ducts disruptions has increased. Despite many publications available in current literature, concerning the endoscopic treatment of consequences of acute necrotizing pancreatitis, the role of transpapillary drainage in management of patients with pancreatic fluid collections and pancreatic duct disruption as an after-effect of severe acute pancreatitis remains unclear and is still a current problem. This publication includes comment on the article entitled 'Early dual drainage combining transpapillary endotherapy and percutaneous catheter drainage in patients with pancreatic fistula associated with severe acute pancreatitis' published by Yokoi et al. in the July-August 2016 issue of Pancreatology together with questions to the authors. Furthermore, in the article we did pay particular attention to the role of transpapillary drainage in management of pancreatic fluid collections, especially of walled-of pancreatic necrosis. [ABSTRACT FROM AUTHOR]

Background: The development of pancreatic fistula (PF) associated with pancreatic necrosis is of great concern in the management of severe acute pancreatitis (SAP). We expected that early recognition and intervention of PF combined with percutaneous catheter drainage (PCD) for pancreatic infection may improve SAP outcomes., Methods: Fifteen consecutive patients with SAP were enrolled. Whenever feasible, fine-needle aspiration for fluid collection was performed to determine infection and amylase concentration. For infection and PF with amylase-rich fluid, PCD and transpapillary endotherapy (preferably naso-pancreatic drainage) were carried out as soon as possible. PCD was intensively managed by irrigating the sized-up and multiple large bore catheters., Results: Infected fluid collection and PF were both detected in 13 (86.7%) patients. Pancreatic duct (PD) disruption (n = 6) and organ failure (n = 5) occurred exclusively in patients with amylase-rich collection ≥10,000 U/L. The median timing of PCD and endotherapy was 15.5 and 16.5 days, respectively. No serious complications or mortality resulted from intervention procedures other than stent occlusion in one (6.7%) patient. Surgical intervention due to uncontrollable infection and visceral organ injury was avoided. Fistula closure was achieved in 12 (92.3%) of 13 PF patients with a median duration of 45 days. Disease-related mortality occurred in one (6.7%) patient., Conclusion: Amylase-rich fluid collection ≥10,000 U/L may be an indication for further endoscopic investigation of PD disruption. Early dual drainage combining pancreatic endotherapy and PCD is feasible and safe, and may improve treatment outcome., (Copyright © 2016. Published by Elsevier B.V.)