A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis

mBackground: The end result of leakage of pancreatic juice into the peripan creatic space can be sterile necrosis, infected necrosis, or rupture into a n adjacent hollow viscus or blood vessel (eg, colon, small bowel, or pseudo aneurysm). If a pancreatic duct (PD) leak is present, should treatment be a imed at minimizing the sequela of the leakage of pancreatic juice and not j ust supportive observation until a necrosectomy is required? Methods: In 144 patients with severe pancreatitis we investigated whether t he presence of a PD leak was associated with necrosis and also asked if PD leak might predict other outcomes such as a length of stay (LOS), mortality , and need for surgery. Furthermore, we questioned whether the use of endos copic retrograde cholangiopancreatography (ERCP) to search for a PD leak mi ght worsen the clinical outcome because of the potential for introducing mi croorganisms into an undrained space or exacerbating pancreatitis. Results: The presence of a demonstrable pancreatic duct leak was observed i n 37% of patients and Was significantly associated with both a higher incid ence of necrosis and prolonged LOS (greater than or equal to 20 days). Thes e patients were 3.4 times more likely to have necrosis and 2.6 times more l ikely to have a prolonged LOS. When treated with a combination of percutane ous drains, pancreatic duct stents, and surgery as necessary, a PD leak (ev en with its higher necrosis rate) was not significantly correlated with eit her mortality or the need for necrosectomy. The use of ERCP was not associa ted with LOS, mortality, or the need for necrosectomy, provided discovered PD leaks were immediately drained. Conclusions: A PD leak is common in patients with pancreatic necrosis but i t is also important to locate and decompress in order to impede progession of the disease and keep mortality low. (C) 2001 Excerpta Medica, Inc. All r ights reserved.