Copyright © ESPGHAN and NASPGHAN. All rights reserved. Disconnected Pancreatic Duct in Children With Walled OFF Necrosis: Impact on Outcomes of Endoscopic Drainage Zaheer Nabi, Jahangeer Basha, Sundeep Lakhtakia, Upender Shava, Partha Pal, Mohan Ramchandani, Rajesh Gupta, Rakesh Kalapala, Santosh Darisetty, Manu Tandan, and Duvuur Nageshwar Reddy ABSTRACT Objectives: Disconnected pancreatic duct syndrome (DPDS) is frequently encountered in cases with walled off necrosis (WON). The impact of DPDS on the outcomes of pancreatic fluid collections (PFCs) is not well known. In this study, we aim to evaluate the incidence of DPDS and its clinical impact on the outcomes of endoscopic ultrasound (EUS)-guided drainage of PFC in children. Methods: All children with symptomatic WON who underwent EUS-guided drainage using metal stents were included in the study. At 4 weeks, pancreatic ductal anatomy was evaluated, and metal stents removed. All the children were followed at regular intervals and evaluated for the recurrence of PFC and the development of new-onset diabetes. Results: A total of 32 children (28 boys, median age 15 years) underwent EUS-guided drainage of WON. Resolution of WON was documented in all children at 4 weeks. Pancreatic ductal anatomy using magnetic resonance retrograde cholangiopancreatography and endoscopic retrograde pancreatography was available in 30 (93.7%) children. Of these, DPDS was documented in 25 (83.3%) children including proximal disconnection in 12 and distal disconnection in 13 children. Recurrent PFC and new-onset diabetes were found in 5 (20%) and 2 (8%) children with DPDS, respectively. Of the 5 recurrences of PFC, endoscopic reintervention was required in 3 children. Conclusions: Majority of the children with DPDS do not develop a symptomatic recurrence of PFC after the removal of cystogastric stents. DPDS may be a risk factor for the development of new-onset diabetes. However, future prospective studies are needed. Key Words: disconnected pancreatic duct, endoscopy, pancreatic fluid collection (JPGN 2019;69: 116–119) W alled off necrosis (WON) is an encapsulated collection of pancreatic and/or peripancreatic necrosis with a well- defined inflammatory wall that usually develops at about 4 weeks or more after the onset of necrotizing pancreatitis (1). Endoscopic drainage of WON has been shown to be safe and effective in adult patients and gaining momentum in children as well (2–4). The endoscopic management of WON has, however, not been ade- quately evaluated in pediatric patients. WON is frequently associated with disconnected pancreatic duct syndrome (DPDS) in which the disruption of main pancreatic duct results in the isolation of a variable portion of upstream pancreas (5). The presence of DPDS may have significant impact on the outcome of endoscopic drainage of pancreatic fluid collec- tions (PFCs) including more frequent requirement of reinterven- tions and rescue surgery (5). The impact of DPDS on the course of WON has not been evaluated in pediatric patients. In this study, we aim to evaluate the incidence of DPDS and its impact on the outcome of endoscopic ultrasound (EUS)-guided drainage of WON using bi-flanged metal stent (BFMS) in children. METHODS Consecutive children (18 years) with symptomatic WON who underwent EUS-guided drainage using BFMS were included in the study. Children with pseudocysts and those who underwent percutaneous drainage or endoscopic drainage using plastic stents were excluded from the study. The study was conducted at a tertiary care center and approved by institutional ethical review board (AIG/ What Is Known  Pancreatic fluid collections are a known complication of acute severe pancreatitis.  Endoscopic drainage is increasingly being used in children with walled off necrosis.  Walled off necrosis may be associated with discon- nected pancreatic duct. The frequency of discon- nected pancreatic duct and its impact on outcomes of endoscopic drainage are not well known in children. What Is New  Endoscopic drainage using metal stents is effective in children with walled off necrosis.  Disconnected pancreatic duct is frequent in children with walled off necrosis and is associated with recur- rence of pancreatic fluid collection.  Majority of children with disconnected pancreatic duct, however, do not develop a symptomatic recur- rence of fluid collection. Received January 3, 2019; accepted April 11, 2019. From the Asian Institute of Gastroenterology, Hyderabad, India. Address correspondence and reprint requests to Zaheer Nabi, MD, DNB, 6- 3-661, Asian Institute of Gastroenterology, Hyderabad-500082, India (e-mail: zaheernabi1978@gmail.com). The authors report no conflicts of interest. Copyright # 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0000000000002367 ORIGINAL ARTICLE:PANCREATOLOGY 116 JPGN  Volume 69, Number 1, July 2019