A Step-Up Approach Using Alternative Endoscopic Modalities Is an Effective Strategy for Postoperative and Traumatic Pancreatic Duct Disruption

Background and Aims Standard endotherapy for pancreatic duct (PD) disruption is pancreatic stenting and sphincterotomy. In patients refractory to standard treatment, treatment algorithm is currently not standardized. This study aims to report the 10-year experience with the endoscopic treatment of postoperative or traumatic PD disruption and to share our algorithmic approach. Methods This retrospective study was conducted on 30 consecutive patients who underwent endoscopic treatment for postoperative ( n = 26) or traumatic ( n = 4) PD disruption between 2011 and 2021. Standard treatment was initially applied to all patients. Endoscopic modalities used with a step-up approach in patients unresponsive to standard treatment were stent upsizing and N -butyl-2-cyanoacrilate (NBCA) injection for partial disruption, and the bridging of the disruption with a stent and cystogastrostomy for complete disruption. Results PD disruption was partial in 26 and complete in 4 patients. Cannulation and stenting of PD was successful in all patients and sphincterotomy was performed in 22 patients. Standard treatment was successful in 20 patients (66.6%). The resolution of PD disruption in 9 of 10 patients refractory to standard treatment was achieved with stent upsizing in 4, NBCA injection in 2, the bridging of the complete disruption in one, and cystogastrostomy after spontaneously and intentionally developed pseudocyst in one patient each. Overall, therapeutic success rate was 96.6% (100% for partial, 75% for complete disruption). Procedural complications occurred in 7 patients. Conclusions Standart treatment for PD disruption is usually effective. In patients refractory to standard treatment, the outcome may be improved by step-up approach using alternative endoscopic modalities.