Timing and location are keys: ERCP success and its benefit in MPD injury post-acute pancreatitis

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This study aimed to verify the factors linked to the technical success of transpapillary drainage by Endoscopic retrograde cholangiopancreatography (ERCP) in managing the MPD injury, and the impact of technical success on the tube duration and overall survival. Methods A retrospective analysis was conducted on patients who underwent ERCP procedures for MPD injuries following acute pancreatitis from May 2019 to April 2021. Univariate and multivariate logistic regression analyses were employed to identify factors associated with successful treatment. Kaplan-Meier curves were used to analyze the impact of technical success on the tube duration and overall survival rate of patients. Results We included 63 patients in whom the MPD opacification was achieved (43 technical succeed and 20 failed). The successful groups exhibited a higher percentage of interval from onset of acute pancreatitis to the endoscopic trans-papillary drainage procedure (IOP) less than 90 days (58.14%) compared to the failed group (20.00%) ( P = 0.005). This study indicated a statistically significant association between the success rate of endoscopic trans-papillary drainage procedure with IOP less than 90 days (95% CI: 0.06–0.91, P = 0.036) and MPD injury occurred in areas other than the head and neck of the pancreas (95% CI: 1.10-19.77, P = 0.036). Technical successful group (median TD time: 10.3 months, 95% CI: 7.3–13.3) shorten the tube indwelling time compared with technical failed group (median TD time: 16.8 months, 95% CI: 12.3–21.3) ( P = 0.025). Conclusions ERCP should be performed within 90 days in patients with MPD injury, and has a higher success rate with injury occurred in areas other than the head and neck of the pancreas. The technical success could shorten indwelling time of the drainage tube and improve patients' life quality. Acute necrotizing pancreatitis Main pancreatic duct injury Endoscopic retrograde cholangiopancreatography Transpapillary drainage Figures Figure 1 Figure 2 Introduction Acute pancreatitis is a prevalent gastrointestinal emergency in clinical settings, with its frequency steadily rising over time, leading to substantial strain on the healthcare system [ 1 ]. In the United States alone, the cumulative annual health care expenditures for acute pancreatitis have surpassed $ 3.0 billion in recent years [ 2 , 3 ]. Theoretically, in cases of acute necrotizing pancreatitis, necrosis of the pancreatic parenchyma poses a significant risk of damage to the main pancreatic duct (MPD). Injuries to the MPD may result in the development of acute peri-pancreatic fluid collection (APFC) or acute necrotic collection (ANC) within the initial four weeks, or persistent leakage of pancreatic juice through fistulas to the skin or adjacent organs following drainage. This often leads to prolonged hospital stays, nutritional imbalances, skin complications, and heightened mortality rates, indicating a substantial long-term morbidity [ 4 , 5 ]. There is a lack of comprehensive epidemiological data regarding the occurrence and progression of main pancreatic duct (MPD) injury in cases of acute necrotizing pancreatitis. A previous study has shown that individuals with a disrupted pancreatic duct have a significantly lower success rate with percutaneous drainage alone (0% compared to 63.6%) and a significantly higher likelihood of requiring operative debridement (84.5% compared to 39.3%) when compared to those with an intact pancreatic duct [ 6 ]. Various conservative therapies, such as antibiotics and nutritional support, percutaneous drainage, transmural drainage, transpapillary drainage, surgery, and other interventions, have been documented as strategies for managing pancreatic fistulas [ 7 , 8 ]. Transpapillary pancreatic duct stenting by endoscopic retrograde cholangiopancreatography (ERCP) is considered the primary treatment modality among these options [ 9 , 10 ]. Multiple studies have indicated that trans-papillary drainage is a viable and efficacious treatment option for pancreatic fistula [ 11 – 21 ]. Nevertheless, a challenge arises with transpapillary drainage during the performance of this procedure, as successful prosthesis insertion is not always guaranteed. The potential risk factors associated with unsuccessful endoscopic trans-papillary prosthesis insertion remain unclear. Consequently, we performed a retrospective analysis of patients who underwent endoscopic transpapillary drainage to examine the factors influencing the success rate of stent or nasopancreatic tube placement, as well as the impact of successful ERCP on clinical outcomes. Methods Statement of ethics and trial registration The study protocol received approval from the Jinling Hospital Ethics Committee (2019NZKY-003-01) and adheres to the principles outlined in the Declaration of Helsinki. Written informed consent was obtained from all participants in the study. Study design The study utilized a prospectively maintained database of patients diagnosed with acute pancreatitis at Jinling Hospital (Nanjing, China) to retrospectively collect data on individuals who underwent endoscopic transpapillary drainage for main pancreatic duct (MPD) injuries following acute pancreatitis between May 2019 and April 2021. In patients with acute pancreatitis, indications for performing an ERCP include a strong suspicion of injury to the main pancreatic duct. Contraindications are predominantly characterized by unstable vital signs and the presence of intra-abdominal hypertension. The study consisted of two parts. Firstly, we analyzed the influencing factors of transpapillary drainage via ERCP, by dividing the patients into two groups (a technical successful group and a technical failed group). Subsequently, we explore the impact of successful transpapillary drainage via ERCP on outcomes, including the tube duration and overall survival, based on a 3-year follow-up. Data collection Electronic health records were carefully examined to gather information on patient demographics, etiology of pancreatitis, therapeutic interventions administered, findings and interventions during endoscopic retrograde cholangio-pancreatography (ERCP). The contents of follow-up included the survival status of patients, the removal time of the last drainage tube. Definition Acute pancreatitis was diagnosed utilizing the revised Atlanta classification and definitions, which necessitated the presence of two out of three specified criteria: (1) abdominal pain indicative of acute pancreatitis (sudden onset of severe, persistent epigastric pain often radiating to the back); (2) serum lipase activity (or amylase activity) exceeding three times the upper limit of normal; and (3) characteristic imaging findings of acute pancreatitis on contrast-enhanced computed tomography (CECT), and less frequently on magnetic resonance imaging (MRI) or transabdominal ultrasonography [ 22 – 24 ]. Patients diagnosed with acute necrotizing pancreatitis at our facility underwent treatment utilizing a "STEP-UP" approach, which involved initial percutaneous drainage followed by minimally invasive retroperitoneal necrosectomy if deemed necessary [ 25 ]. The manifestation of main MPD injury was characterized by the enlargement of APFC or ANC, and the development of new pancreatic pseudocysts or pancreatic fistulas. The criteria for diagnosing MPD injury were based on the final diagnosis established at our center, which was judged by clinical evaluation combined with enhanced computed tomography (CT) scans and/or ERCP [ 26 ]. A pancreatic fistula was specifically defined as the presence of drain fluid with an amylase level exceeding three times the upper limit of normal for the institution following percutaneous drainage [ 27 ]. The technical success of transpapillary drainage via ERCP was defined by the successful placement of a prosthesis through the papilla into the defect region of the main pancreatic duct. Conversely, technical failure was characterized by the inability to insert a prosthesis through the papilla into the defect area of the main pancreatic duct. Main outcomes of the study were (1) overall survival (OS), defined as the time from ERCP procedure to death or last follow-up; (2) tube duration (TD), defined as the time from the first tube inserted to last tube removed throughout the course of disease treatment. Technique Initially, pancreatic duct cannulation was performed using a floppy tip guidewire. Our goal was to bridge the pancreatic duct with a prosthesis in all patients, a task that proved to be challenging. Two trans-papillary intervention options were evaluated: stent insertion and nasal-pancreatic tube placement. The selection of intervention was determined by the attending physician, with the choice of stent being guided by the specific ductal anatomy of the patient. The strictures were progressively dilated utilizing a sphincterotome (Autotome RX 44 Cannulating Sphincterotome, Boston Scientific) and 7F dilators (Fusion Biliary Dilation Catheter, FS-BDC-7, Cook Medical). Following this, a 5- or 7-Fr trans-papillary pancreatic stent or a nasal-pancreatic tube (Cook Medical) was carefully inserted over a guidewire into the pancreatic duct, extending to the site of the defect when feasible. These interventions were conducted by a single proficient endoscopist. Statistical analysis Categorical variables were assessed utilizing the chi-squared test and Fisher exact test, while continuous variables were evaluated using the Student t-test and Wilcoxon rank sum test. Multivariable logistic regression was conducted to examine factors correlated with technical success, candidate variables with a P value < 0.1 in univariate analysis and variance inflation factors (VIFs) less than 5, were included in multivariable model. Median OS and TD in months with corresponding 95% CIs were estimated with Kaplan-Meier curves and compared using the log-rank test. Statistical significance was defined as a P < 0.05. All statistical analyses were performed using IBM SPSS version 26.0 (IBM Corp.). Results Baseline demographics and clinical characteristics A total of 78 patients diagnosed with MPD injuries following acute necrotizing pancreatitis were identified at our center between May 2019 and April 2021. Among them, 63 patients successfully underwent MPD opacification using ERCP. The remaining 15 patients encountered difficulties in locating the MPD due to issues such as pancreatic duct cannulation (10 patients), duodenal edema (4 patients), and pyloric edema (1 patient). Subsequent analysis was conducted based on the data from the 63 patients who successfully underwent the procedure. In order to further assess the possible bias introduced by excluding these patients, we analyzed the baseline characteristics of included individuals and excluded individuals, and most of the baseline characteristics between them were of no difference, as illustrated in Supplementary Material 1. The cohort consisted of 41 male patients (65.08%) and 22 male patients (34.92%), with a median age of 43.63 years. The primary etiologies of acute pancreatitis in this group included biliary-related (66.67%), hypertriglyceridemia-related (30.16%), and others (alcohol-related, trauma-related, post-pancreatic surgery-related, etc.). Prior to undergoing endoscopic transpapillary drainage, all patients experienced peri-pancreatic local complications, including ANC (12.70%), APFC (1.59%), infected pancreatic necrosis (IPN, 14.29%), pancreatic pseudocyst (PP, 26.98%), walled-off necrosis (WON, 34.92%), and others (9.52%). The successful groups exhibited a higher percentage of interval from onset of acute pancreatitis to the endoscopic trans-papillary drainage procedure (IOP) less than 90 days (58.14%) compared to the failed group (20.00%) ( P = 0.005). Detailed information was shown in Table 1 . Table 1 Baseline demographics and clinical characteristics of endoscopic trans-papillary drainage according to technical success or failure Variables Total (n = 63) Technical success (n = 43) Technical failure (n = 20) P Sex, n (%) 0.576 Male 41 (65.08) 27 (62.79) 14 (70.00) Female 22 (34.92) 16 (37.21) 6 (30.00) Age (yr), mean (SD) 43.63 ± 13.86 45.26 ± 13.54 40.15 ± 14.24 0.175 BMI (kg/m 2 ), mean (SD) 24.25 ± 3.94 24.84 ± 3.53 22.99 ± 4.55 0.083 Aetiology, n (%) 1.000 Biliary 42 (66.67) 28 (65.12) 14 (70.00) Hypertriglyceridemia Others 19 (30.16) 2 (3.17) 13 (30.23) 2 (4.65) 6 (30.00) 0 (0.00) Local complications (%) 0.736 ANC 8 (12.70) 6 (13.95) 2 (10.00) APFC 1 (1.59) 1 (2.33) 0 (0.00) IPN 9 (14.29) 7 (16.28) 2 (10.00) PP 17 (26.98) 9 (20.93) 8 (40.00) WON 22 (34.92) 15 (34.88) 7 (35.00) Others 6 (9.52) 5 (11.63) 1 (5.00) IOP < 90days, n (%) 29 (46.03) 25 (58.14) 4 (20.00) 0.005 Constant organ failure before 14 (22.22) 10 (23.26) 4 (20.00) 1.000 ERCP, n (%) WBC, median (IQR) 6.46 (4.69, 8.75) 7.09 (4.88, 9.06) 5.87 (4.31, 7.62) 0.275 CRP (mg/L), median (IQR) 14.30 (1.90, 50.15) 20.3 (3.30, 67.40) 3.95 (1.10, 30.63) 0.081 Used somatostatin or its 35 (55.56) 25 (58.14) 10 (50.00) 0.545 analogues, n (%) Serum albumin (g/L), mean (SD) 36.03 ± 5.34 35.18 ± 5.34 37.85 ± 5.00 0.065 MPD injury location 0.090 Head and neck 41 (65.08) 25 (58.14) 16 (80.00) Other parts 22 (34.92) 18 (41.86) 4 (20.00) ANC, Acute necrotic collection; APFC, Acute peri-pancreatic fluid collection; BMI, body mass index; CRP, C-reactive protein; ds, days; ERCP, Endoscopic retrograde cholangio-pancreatography; IOP, Interval from onset of acute pancreatitis to the endoscopic trans-papillary drainage procedure; IQR, Interquartile range; IPN, Infected pancreatic infection; MPD, Main pancreatic duct; PP, Pancreatic pseudocyst; SD, Standard Deviation; WON, Walled-off necrosis; WBC, white blood cell; yr, year. Findings of MPD opacification by ERCP Pancreatography revealed contrast extravasation from the main pancreatic duct in 39 out of 63 patients, with confirmed disruptions or disconnections in various locations: 23 in the head and neck, 9 in the body, and 7 in the tail. Another 24 patients exhibited no evidence of contrast extravasation, with 18 instances of main pancreatic duct occlusion: 16 localized in the head and neck, 1 in the body, and 1 in the tail. Additionally, 6 cases demonstrated an intact main pancreatic duct, while the pancreatic fistula originated from a branch duct. We endeavored to implant a prosthesis in all 63 patients, positioning the proximal end of the prosthesis (either a stent or nasal-pancreatic tube) adjacent to or within the disruption in cases of evident contrast extravasation, and adjacent to or within the distal non-opacification segment of the pancreatic duct in cases without contrast extravasation (Supplementary Material 2). Nasal-pancreatic tubes were utilized in 19 patients (44.19%), 5Fr stents in 22 patients (51.16%), and 7Fr stents in 2 patients (4.65%). The choice of stent length was based on the location of the pancreatic duct defect. Of all the patients who underwent ERCP, one patient developed infected pancreatic necrosis. Technical success was achieved in 43 out of 63 patients. The characteristics of successful and failed endoscopic trans-papillary drainage procedures are detailed in Table 1 . The successful groups exhibited a higher percentage of IOP less than 90 days compared to the failed group (Table 1 ). IOP and MPD injury locations affect the success rate of ERCP Univariate regression analysis showed that the successful group exhibited a higher percentage of IOP less than 90 days at 58.14% compared to the failed group at 20.00%. Additionally, there were no other statistically significant intergroup differences observed in terms of technical success or failure (Supplementary Material 3). A multivariable logistic regression model was developed incorporating variables ( P < 0.1 in univariate analysis and variance inflation factors (VIFs less than 5) including IOP < 90 days, MPD injury locations, BMI and serum albumin. The findings indicated a statistically significant association between the success rate of endoscopic trans-papillary drainage procedure with IOP less than 90 days (95% CI: 0.06–0.91, P = 0.036) and MPD injury occurred in areas other than the head and neck of the pancreas (95% CI: 1.10-19.77, P = 0.036) (Table 2 ). Table 2 Multivariable logistic regression for predictors of technical success in patients with pancreatic duct injury undergoing ERCP Variable OR (95% CI) P IOP < 90 days 0.23 (0.06–0.91) 0.036 MPD injury location 4.67 (1.10-19.77) 0.036 BMI 1.10 (0.93–1.31) 0.275 Serum albumin 0.90 (0.80–1.02) 0.088 Abbreviations: BMI, body mass index; CI: Confidence Interval; ERCP, Endoscopic retrograde cholangio-pancreatography; IOP, Interval from onset of acute pancreatitis to the endoscopic trans-papillary drainage procedure; MPD, Main pancreatic duct; OR: Odds Ratio. Technical success could short the tube indwelling time In the study, there were 6 patients of loss to follow-up, with 4 in the successful group and 2 in the failed group (Fig. 1 ). Possible reasons may include changes in contact information, etc. A statistically significant difference was observed in tube duration between the technical successful group (median TD time: 10.3 months, 95% CI: 7.3–13.3) and the technical failed group (median TD time: 16.8 months, 95% CI: 12.3–21.3) (Log-Rank P = 0.025) (Fig. 2 A). The median survival times for the technical successful group (32.5 months, 95% CI: 29.9–35.1) and the technical failed group (31.8 months, 95% CI: 27.4–36.2) did not exhibit a statistically significant difference (Log-Rank P = 0.939) (Fig. 2 B). Discussion This retrospective observational study indicated that patients who were diagnosed with MPD injury following acute necrotizing pancreatitis exhibited a high success rate when undergoing endoscopic transpapillary drainage at an earlier stage (< 90 days) and MPD injury occurred in areas other than the head and neck of the pancreas compared to those who did not. Technical success is beneficial in reducing the catheter indwelling duration, though it does not significantly impact survival rates. In 1991, Dr. Richard A. Kozarek pioneered the utilization of endoscopic transpapillary therapy in a cohort of 18 patients presenting with active pancreatic disruption, specifically pancreatic fistula. This initial study indicated that transpapillary intervention for persistent pancreatic ductal disruption may offer a non-surgical alternative for certain patients, potentially converting an emergent surgical intervention into an elective procedure, or aiding the surgeon in conducting intraoperative pancreatography [ 28 ]. Based on data from multicenter studies, it has been indicated that endoscopic transpapillary stenting may serve as a viable and secure option compared to conservative management for individuals with pancreatic fistulas [ 16 ]. The research conducted by Dr. Shyam Varadarajulu [ 19 ] and Dr. Surinder Singh Rana [ 17 ] identified key factors that predict the success of endoscopic trans-papillary drainage, specifically the presence of bridging in the disrupted duct and the type of disruption. Nevertheless, achieving bridging of a pancreatic stent with an endoscope may prove challenging, particular in cases where the pancreatic duct is completely disconnected. A separate investigation demonstrated high effectiveness of transpapillary drainage and clinical success observed in 86.7%. The methodology employed in the study involved deploying the proximal ends of stents in close proximity to or within the disruption, when bridging was not a viable option for any patient [ 11 ]. So, in our study, technical success was defined as that. The aforementioned studies exhibited limitations, including a focus solely on patients who successfully underwent transpapillary drainage, without thorough analysis of those who failed to undergo the procedure. In our study, a subset of patients (20 out of 63, or 31.7%) did not successfully complete the entire procedure. After comparing the clinical and interventional characteristics, it was established that the performance of endoscopic transpapillary drainage during the advanced stage of the disease may reduce the likelihood of successful prosthesis implantation. This could be attributed to the development of stenosis and obstruction in the pancreatic duct due to long-term treatment of acute necrotizing pancreatitis, resulting in difficulty for a guidewire to pass through. Therefore, we established a 90-day threshold for the interval between the onset of acute pancreatitis and the implementation of trans-papillary drainage. The percentages of patients with intervals of less than 90 days in the two groups were 58.14% (Technical success group) and, 20.00% (Technical failure group) respectively ( P = 0.011). Further multivariable logistic regression analysis indicated a statistically significant association between the technical success rate within 90 days of onset. The findings suggested that performing transpapillary drainage earlier, specifically within 90 days of symptom onset, may enhance the success rate of prosthesis insertion. Moreover, delayed diagnosis due to insufficient awareness of the disease, coupled with prolonged reliance on conservative treatments such as medication and extended observation periods, can lead to postponed endoscopic intervention (> 90 days), potentially raising the risk of technical complications in transpapillary drainage procedures. Nevertheless, the utilization of trans-papillary drainage is associated with several limitations, including the potential risk of infection in a previously sterile collection. A prospective randomized study has been initiated to assess the feasibility and safety of prophylactic pancreatic duct stenting in cases of acute necrotizing pancreatitis, in comparison to conservative treatment. Patients assigned to the intervention group are scheduled to undergo ERCP as promptly as possible, ideally within the first week following the onset of symptoms [ 29 ]. The study was halted prematurely on ethical grounds due to a higher incidence of infection among patients with successful pancreatic duct prosthesis placement (5/5, 100%) compared to those in the conservative treatment group (3/13, 23.1%; P = 0.01). Therefore, early implementation of endoscopic trans-papillary drainage for patients with acute pancreatitis is not advisable. In addition, the diagnosis of pancreatic duct injury manifested as pancreatic fistula can be challenging, as radiological changes indicating peri-pancreatic local complications are often indistinct during the initial stages of acute necrotizing pancreatitis (< 2 weeks) as the disease and necrosis progress. However, by the 2-week mark, computed tomography typically reveals identifiable changes indicative of pancreatic duct disruption or pancreatic fistula [ 30 ]. Considering the risk of early infection and the fact that pancreatic fistula can only be indicated by imaging after 2 weeks, we recommend performing ERCP after 2 weeks. The location of MPD injury was also an important factor affecting the technical success, with a higher success rate when the injury occurred in areas other than the head and neck of the pancreas. The injuries near the pancreatic head and neck were more likely to cause distortion and deformation of the duodenum, which further lead to difficulties in intubation; on the other hand, such injuries are more prone to form submucosal scars and pancreatic duct distortion. During the operation, it is difficult for the incision knife and guide wire to enter, and the stent was hard to fix with poor adhesion, thus failing to achieve a good drainage. Further analysis was performed on the outcomes, including the removal time of the last drainage tube and the survival status of patients. This study suggested it is beneficial in reducing the catheter indwelling duration. Statistically significant difference in mortality between the two groups was not observed. Patients suffering from severe acute pancreatitis exhibit an increased likelihood of requiring long-term placement of a peripancreatic drainage tube as a consequence of their condition. This necessity is particularly pronounced in patients who develop infections or pancreatic fistulas, where the insertion of a drainage tube becomes imperative. However, the duration of tube indwelling is different for each patient. The main factors affecting the indwelling time of drainage tubes included the patient's nutritional status, the properties and volume of drainage fluid, and the severity of disease. Wearing a tube for a long time can cause many consequences, including pain, infection, granulation hyperplasia, tube breakage, displacement, blockage, and sinus bleeding. Our study selected patients with severe pancreatitis who had been highly suspected of pancreatic duct injury by imaging, and the time span was large. The influence factors between the technical successful group and the technical failed group were analyzed. It is found that in patients with severe pancreatitis complicated with pancreatic duct injury, MPD injury occurred in areas other than the head and neck of the pancreas and ERCP performed within 90 days showed a high success rate, which can significantly shorten the time of drainage tube and improve the quality of life of patients. Study limitations include its retrospective design, a small number of cases included, and the difficulty in studying large patient cohorts due to the low incidence of pancreatic fistula. A single-center study may have selection bias. Conclusion Our study explores the occurrence of MPD and highlights the high success rate associated with earlier (< 90 days) endoscopic transpapillary drainage and MPD injury occurred in areas other than the head and neck of the pancreas, which could shorten indwelling time of the drainage tube and improve the patients' quality of life. Declarations Ethical approval and consent to participate All procedures were performed in accordance with the ethical standards of the institutional committee. Written informed consent was obtained from all participants in the study. The study protocol received approval from the Jinling Hospital Ethics Committee and adheres to the principles outlined in the Declaration of Helsinki. Consent for publication All data in this publication are presented in an entirely anonymized manner. No individual patient details that could compromise privacy are disclosed. Competing interests The authors declare no competing interests. Funding None. Author Contribution Zhijun Su participated in data collection, statistical analysis, writing-original draft, supervision; Xiang Li participated in data curation, writing-review and editing, supervision; Xiaojia Xiao participated in data collection, follow-up; Bo Ye participated in data curation, methodology, supervision; Zhihui Tong participated in methodology, supervision; Weiqin Li participated in methodology, writing-review and editing, supervision. Acknowledgements None. Data Availability The data that support the findings of this study are available on request from the corresponding author. References Iannuzzi JP, King JA, Leong JH, et al. Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis. Gastroenterology. 2022;162(1):122–34. Peery AF, Crockett SD, Murphy CC, et al. Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2018. Gastroenterology. 2019;156(1):254–e7211. 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Karjula H, Nordblad Schmidt P, Makela J, et al. Prophylactic pancreatic duct stenting in severe acute necrotizing pancreatitis: a prospective randomized study. Endoscopy. 2019;51(11):1027–34. Larsen M, Kozarek RA. Management of Disconnected Pancreatic Duct Syndrome. Curr Treat Options Gastroenterol. 2016;14(3):348–59. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial1.docx SupplementaryMaterial2.docx SupplementaryMaterial3.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8010012","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":565374364,"identity":"937b1026-1eb7-4340-bb2b-22486f9e58a8","order_by":0,"name":"Zhijun Suo","email":"","orcid":"","institution":"Southern Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhijun","middleName":"","lastName":"Suo","suffix":""},{"id":565374365,"identity":"7adbd134-e476-43f6-a21d-4341390cd24f","order_by":1,"name":"Xiang Li","email":"","orcid":"","institution":"Shenzhen Nanshan People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiang","middleName":"","lastName":"Li","suffix":""},{"id":565374366,"identity":"bdd8c22d-ea82-4bfb-9f37-c04c561c0bc4","order_by":2,"name":"Xiaojia Xiao","email":"","orcid":"","institution":"Shenzhen Nanshan People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaojia","middleName":"","lastName":"Xiao","suffix":""},{"id":565374367,"identity":"e75076d8-a19b-46c0-9ac1-d96fe4100e48","order_by":3,"name":"Bo Ye","email":"","orcid":"","institution":"Medical School of Nanjing University","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Ye","suffix":""},{"id":565374368,"identity":"616a0860-841b-4a50-a27e-8a03919d6129","order_by":4,"name":"Zhihui Tong","email":"","orcid":"","institution":"Medical School of Nanjing 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16:29:37","extension":"html","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":109350,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8010012/v1/0b0a467057a57c807ba0d5b9.html"},{"id":99218143,"identity":"15945e67-58e1-4dcc-ba9b-2de7b6d784d8","added_by":"auto","created_at":"2025-12-30 09:16:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":160604,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants screen flow chart of the study.\u003c/p\u003e","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8010012/v1/735777077247bb705c6ed2a7.png"},{"id":99218144,"identity":"03fdc04d-1e79-4156-994c-ee682f15d8ec","added_by":"auto","created_at":"2025-12-30 09:16:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":151799,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curves of (A) TD probability (\u003cem\u003eP\u003c/em\u003e = 0.025) and (B) survival probability (\u003cem\u003eP\u003c/em\u003e= 0.939).\u003c/p\u003e","description":"","filename":"OnlineFigure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8010012/v1/cbcb73de42c46599295d0eca.png"},{"id":101754535,"identity":"9d2b900b-279f-4ec5-933e-0b37dce09aa1","added_by":"auto","created_at":"2026-02-03 10:42:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1144247,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8010012/v1/ac44f4df-2116-48fc-b2fd-22975c00df34.pdf"},{"id":99317194,"identity":"b0391c66-e3c6-4393-acb5-c14cdb09245b","added_by":"auto","created_at":"2025-12-31 16:29:44","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19583,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8010012/v1/b299b7f9e972a72c0617e5c5.docx"},{"id":99218152,"identity":"c70eb5eb-0f00-4688-ab3b-7aab78842adf","added_by":"auto","created_at":"2025-12-30 09:16:41","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":16916,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8010012/v1/a3a941131f34aa642656c4d6.docx"},{"id":99218155,"identity":"6f216d14-fd13-4ea0-b8b2-54e597ded0ec","added_by":"auto","created_at":"2025-12-30 09:16:42","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":20459,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial3.docx","url":"https://assets-eu.researchsquare.com/files/rs-8010012/v1/580df226ac6f997c67876199.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Timing and location are keys: ERCP success and its benefit in MPD injury post-acute pancreatitis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute pancreatitis is a prevalent gastrointestinal emergency in clinical settings, with its frequency steadily rising over time, leading to substantial strain on the healthcare system [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In the United States alone, the cumulative annual health care expenditures for acute pancreatitis have surpassed \u003cspan\u003e$\u003c/span\u003e3.0\u0026nbsp;billion in recent years [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Theoretically, in cases of acute necrotizing pancreatitis, necrosis of the pancreatic parenchyma poses a significant risk of damage to the main pancreatic duct (MPD). Injuries to the MPD may result in the development of acute peri-pancreatic fluid collection (APFC) or acute necrotic collection (ANC) within the initial four weeks, or persistent leakage of pancreatic juice through fistulas to the skin or adjacent organs following drainage. This often leads to prolonged hospital stays, nutritional imbalances, skin complications, and heightened mortality rates, indicating a substantial long-term morbidity [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. There is a lack of comprehensive epidemiological data regarding the occurrence and progression of main pancreatic duct (MPD) injury in cases of acute necrotizing pancreatitis. A previous study has shown that individuals with a disrupted pancreatic duct have a significantly lower success rate with percutaneous drainage alone (0% compared to 63.6%) and a significantly higher likelihood of requiring operative debridement (84.5% compared to 39.3%) when compared to those with an intact pancreatic duct [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVarious conservative therapies, such as antibiotics and nutritional support, percutaneous drainage, transmural drainage, transpapillary drainage, surgery, and other interventions, have been documented as strategies for managing pancreatic fistulas [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Transpapillary pancreatic duct stenting by endoscopic retrograde cholangiopancreatography (ERCP) is considered the primary treatment modality among these options [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Multiple studies have indicated that trans-papillary drainage is a viable and efficacious treatment option for pancreatic fistula [\u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, a challenge arises with transpapillary drainage during the performance of this procedure, as successful prosthesis insertion is not always guaranteed. The potential risk factors associated with unsuccessful endoscopic trans-papillary prosthesis insertion remain unclear. Consequently, we performed a retrospective analysis of patients who underwent endoscopic transpapillary drainage to examine the factors influencing the success rate of stent or nasopancreatic tube placement, as well as the impact of successful ERCP on clinical outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatement of ethics and trial registration\u003c/h2\u003e \u003cp\u003e The study protocol received approval from the Jinling Hospital Ethics Committee (2019NZKY-003-01) and adheres to the principles outlined in the Declaration of Helsinki. Written informed consent was obtained from all participants in the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eThe study utilized a prospectively maintained database of patients diagnosed with acute pancreatitis at Jinling Hospital (Nanjing, China) to retrospectively collect data on individuals who underwent endoscopic transpapillary drainage for main pancreatic duct (MPD) injuries following acute pancreatitis between May 2019 and April 2021.\u003c/p\u003e \u003cp\u003eIn patients with acute pancreatitis, indications for performing an ERCP include a strong suspicion of injury to the main pancreatic duct. Contraindications are predominantly characterized by unstable vital signs and the presence of intra-abdominal hypertension.\u003c/p\u003e \u003cp\u003eThe study consisted of two parts. Firstly, we analyzed the influencing factors of transpapillary drainage via ERCP, by dividing the patients into two groups (a technical successful group and a technical failed group). Subsequently, we explore the impact of successful transpapillary drainage via ERCP on outcomes, including the tube duration and overall survival, based on a 3-year follow-up.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eElectronic health records were carefully examined to gather information on patient demographics, etiology of pancreatitis, therapeutic interventions administered, findings and interventions during endoscopic retrograde cholangio-pancreatography (ERCP). The contents of follow-up included the survival status of patients, the removal time of the last drainage tube.\u003c/p\u003e\n\u003ch3\u003eDefinition\u003c/h3\u003e\n\u003cp\u003eAcute pancreatitis was diagnosed utilizing the revised Atlanta classification and definitions, which necessitated the presence of two out of three specified criteria: (1) abdominal pain indicative of acute pancreatitis (sudden onset of severe, persistent epigastric pain often radiating to the back); (2) serum lipase activity (or amylase activity) exceeding three times the upper limit of normal; and (3) characteristic imaging findings of acute pancreatitis on contrast-enhanced computed tomography (CECT), and less frequently on magnetic resonance imaging (MRI) or transabdominal ultrasonography [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Patients diagnosed with acute necrotizing pancreatitis at our facility underwent treatment utilizing a \"STEP-UP\" approach, which involved initial percutaneous drainage followed by minimally invasive retroperitoneal necrosectomy if deemed necessary [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The manifestation of main MPD injury was characterized by the enlargement of APFC or ANC, and the development of new pancreatic pseudocysts or pancreatic fistulas. The criteria for diagnosing MPD injury were based on the final diagnosis established at our center, which was judged by clinical evaluation combined with enhanced computed tomography (CT) scans and/or ERCP [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. A pancreatic fistula was specifically defined as the presence of drain fluid with an amylase level exceeding three times the upper limit of normal for the institution following percutaneous drainage [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The technical success of transpapillary drainage via ERCP was defined by the successful placement of a prosthesis through the papilla into the defect region of the main pancreatic duct. Conversely, technical failure was characterized by the inability to insert a prosthesis through the papilla into the defect area of the main pancreatic duct. Main outcomes of the study were (1) overall survival (OS), defined as the time from ERCP procedure to death or last follow-up; (2) tube duration (TD), defined as the time from the first tube inserted to last tube removed throughout the course of disease treatment.\u003c/p\u003e\n\u003ch3\u003eTechnique\u003c/h3\u003e\n\u003cp\u003eInitially, pancreatic duct cannulation was performed using a floppy tip guidewire. Our goal was to bridge the pancreatic duct with a prosthesis in all patients, a task that proved to be challenging. Two trans-papillary intervention options were evaluated: stent insertion and nasal-pancreatic tube placement. The selection of intervention was determined by the attending physician, with the choice of stent being guided by the specific ductal anatomy of the patient. The strictures were progressively dilated utilizing a sphincterotome (Autotome RX 44 Cannulating Sphincterotome, Boston Scientific) and 7F dilators (Fusion Biliary Dilation Catheter, FS-BDC-7, Cook Medical). Following this, a 5- or 7-Fr trans-papillary pancreatic stent or a nasal-pancreatic tube (Cook Medical) was carefully inserted over a guidewire into the pancreatic duct, extending to the site of the defect when feasible. These interventions were conducted by a single proficient endoscopist.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eCategorical variables were assessed utilizing the chi-squared test and Fisher exact test, while continuous variables were evaluated using the Student t-test and Wilcoxon rank sum test. Multivariable logistic regression was conducted to examine factors correlated with technical success, candidate variables with a \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.1 in univariate analysis and variance inflation factors (VIFs) less than 5, were included in multivariable model. Median OS and TD in months with corresponding 95% CIs were estimated with Kaplan-Meier curves and compared using the log-rank test. Statistical significance was defined as a \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All statistical analyses were performed using IBM SPSS version 26.0 (IBM Corp.).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eBaseline demographics and clinical characteristics\u003c/h2\u003e \u003cp\u003eA total of 78 patients diagnosed with MPD injuries following acute necrotizing pancreatitis were identified at our center between May 2019 and April 2021. Among them, 63 patients successfully underwent MPD opacification using ERCP. The remaining 15 patients encountered difficulties in locating the MPD due to issues such as pancreatic duct cannulation (10 patients), duodenal edema (4 patients), and pyloric edema (1 patient). Subsequent analysis was conducted based on the data from the 63 patients who successfully underwent the procedure. In order to further assess the possible bias introduced by excluding these patients, we analyzed the baseline characteristics of included individuals and excluded individuals, and most of the baseline characteristics between them were of no difference, as illustrated in Supplementary Material 1.\u003c/p\u003e \u003cp\u003eThe cohort consisted of 41 male patients (65.08%) and 22 male patients (34.92%), with a median age of 43.63 years. The primary etiologies of acute pancreatitis in this group included biliary-related (66.67%), hypertriglyceridemia-related (30.16%), and others (alcohol-related, trauma-related, post-pancreatic surgery-related, etc.). Prior to undergoing endoscopic transpapillary drainage, all patients experienced peri-pancreatic local complications, including ANC (12.70%), APFC (1.59%), infected pancreatic necrosis (IPN, 14.29%), pancreatic pseudocyst (PP, 26.98%), walled-off necrosis (WON, 34.92%), and others (9.52%). The successful groups exhibited a higher percentage of interval from onset of acute pancreatitis to the endoscopic trans-papillary drainage procedure (IOP) less than 90 days (58.14%) compared to the failed group (20.00%) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005). Detailed information was shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline demographics and clinical characteristics of endoscopic trans-papillary drainage according to technical success or failure\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTechnical success\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;43)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTechnical failure\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.576\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (65.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (62.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (70.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (34.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (37.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (30.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (yr), mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.63\u0026thinsp;\u0026plusmn;\u0026thinsp;13.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.26\u0026thinsp;\u0026plusmn;\u0026thinsp;13.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.15\u0026thinsp;\u0026plusmn;\u0026thinsp;14.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e), mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.84\u0026thinsp;\u0026plusmn;\u0026thinsp;3.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.99\u0026thinsp;\u0026plusmn;\u0026thinsp;4.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAetiology, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBiliary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (66.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (65.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (70.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertriglyceridemia\u003c/p\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (30.16)\u003c/p\u003e \u003cp\u003e2 (3.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (30.23)\u003c/p\u003e \u003cp\u003e2 (4.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (30.00)\u003c/p\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal complications (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.736\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eANC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (12.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (13.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAPFC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (14.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (16.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (26.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (20.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (40.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWON\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (34.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (34.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (35.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (9.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (11.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (5.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIOP\u0026thinsp;\u0026lt;\u0026thinsp;90days, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (46.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (58.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant organ failure before\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (22.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (23.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERCP, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.46 (4.69, 8.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.09 (4.88, 9.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.87 (4.31, 7.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.275\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCRP (mg/L), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.30 (1.90, 50.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.3 (3.30, 67.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.95 (1.10, 30.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsed somatostatin or its\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (55.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (58.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (50.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.545\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eanalogues, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin (g/L), mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.03\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.18\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.85\u0026thinsp;\u0026plusmn;\u0026thinsp;5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPD injury location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead and neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (65.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (58.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (80.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther parts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (34.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (41.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eANC, Acute necrotic collection; APFC, Acute peri-pancreatic fluid collection; BMI, body mass index; CRP, C-reactive protein; ds, days; ERCP, Endoscopic retrograde cholangio-pancreatography; IOP, Interval from onset of acute pancreatitis to the endoscopic trans-papillary drainage procedure; IQR, Interquartile range; IPN, Infected pancreatic infection; MPD, Main pancreatic duct; PP, Pancreatic pseudocyst; SD, Standard Deviation; WON, Walled-off necrosis; WBC, white blood cell; yr, year.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFindings of MPD opacification by ERCP\u003c/h2\u003e \u003cp\u003ePancreatography revealed contrast extravasation from the main pancreatic duct in 39 out of 63 patients, with confirmed disruptions or disconnections in various locations: 23 in the head and neck, 9 in the body, and 7 in the tail. Another 24 patients exhibited no evidence of contrast extravasation, with 18 instances of main pancreatic duct occlusion: 16 localized in the head and neck, 1 in the body, and 1 in the tail. Additionally, 6 cases demonstrated an intact main pancreatic duct, while the pancreatic fistula originated from a branch duct. We endeavored to implant a prosthesis in all 63 patients, positioning the proximal end of the prosthesis (either a stent or nasal-pancreatic tube) adjacent to or within the disruption in cases of evident contrast extravasation, and adjacent to or within the distal non-opacification segment of the pancreatic duct in cases without contrast extravasation (Supplementary Material 2). Nasal-pancreatic tubes were utilized in 19 patients (44.19%), 5Fr stents in 22 patients (51.16%), and 7Fr stents in 2 patients (4.65%). The choice of stent length was based on the location of the pancreatic duct defect. Of all the patients who underwent ERCP, one patient developed infected pancreatic necrosis.\u003c/p\u003e \u003cp\u003eTechnical success was achieved in 43 out of 63 patients. The characteristics of successful and failed endoscopic trans-papillary drainage procedures are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The successful groups exhibited a higher percentage of IOP less than 90 days compared to the failed group (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIOP and MPD injury locations affect the success rate of ERCP\u003c/h2\u003e \u003cp\u003eUnivariate regression analysis showed that the successful group exhibited a higher percentage of IOP less than 90 days at 58.14% compared to the failed group at 20.00%. Additionally, there were no other statistically significant intergroup differences observed in terms of technical success or failure (Supplementary Material 3). A multivariable logistic regression model was developed incorporating variables (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.1 in univariate analysis and variance inflation factors (VIFs less than 5) including IOP\u0026thinsp;\u0026lt;\u0026thinsp;90 days, MPD injury locations, BMI and serum albumin. The findings indicated a statistically significant association between the success rate of endoscopic trans-papillary drainage procedure with IOP less than 90 days (95% CI: 0.06\u0026ndash;0.91, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036) and MPD injury occurred in areas other than the head and neck of the pancreas (95% CI: 1.10-19.77, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable logistic regression for predictors of technical success in patients with pancreatic duct injury undergoing ERCP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIOP\u0026thinsp;\u0026lt;\u0026thinsp;90 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.23 (0.06\u0026ndash;0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPD injury location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.67 (1.10-19.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.10 (0.93\u0026ndash;1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.275\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.90 (0.80\u0026ndash;1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAbbreviations: BMI, body mass index; CI: Confidence Interval; ERCP, Endoscopic retrograde cholangio-pancreatography; IOP, Interval from onset of acute pancreatitis to the endoscopic trans-papillary drainage procedure; MPD, Main pancreatic duct; OR: Odds Ratio.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTechnical success could short the tube indwelling time\u003c/h2\u003e \u003cp\u003eIn the study, there were 6 patients of loss to follow-up, with 4 in the successful group and 2 in the failed group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Possible reasons may include changes in contact information, etc. A statistically significant difference was observed in tube duration between the technical successful group (median TD time: 10.3 months, 95% CI: 7.3\u0026ndash;13.3) and the technical failed group (median TD time: 16.8 months, 95% CI: 12.3\u0026ndash;21.3) (Log-Rank \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). The median survival times for the technical successful group (32.5 months, 95% CI: 29.9\u0026ndash;35.1) and the technical failed group (31.8 months, 95% CI: 27.4\u0026ndash;36.2) did not exhibit a statistically significant difference (Log-Rank \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.939) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB).\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eThis retrospective observational study indicated that patients who were diagnosed with MPD injury following acute necrotizing pancreatitis exhibited a high success rate when undergoing endoscopic transpapillary drainage at an earlier stage (\u0026lt;\u0026thinsp;90 days) and MPD injury occurred in areas other than the head and neck of the pancreas compared to those who did not. Technical success is beneficial in reducing the catheter indwelling duration, though it does not significantly impact survival rates.\u003c/p\u003e \u003cp\u003eIn 1991, Dr. Richard A. Kozarek pioneered the utilization of endoscopic transpapillary therapy in a cohort of 18 patients presenting with active pancreatic disruption, specifically pancreatic fistula. This initial study indicated that transpapillary intervention for persistent pancreatic ductal disruption may offer a non-surgical alternative for certain patients, potentially converting an emergent surgical intervention into an elective procedure, or aiding the surgeon in conducting intraoperative pancreatography [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Based on data from multicenter studies, it has been indicated that endoscopic transpapillary stenting may serve as a viable and secure option compared to conservative management for individuals with pancreatic fistulas [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The research conducted by Dr. Shyam Varadarajulu [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and Dr. Surinder Singh Rana [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] identified key factors that predict the success of endoscopic trans-papillary drainage, specifically the presence of bridging in the disrupted duct and the type of disruption. Nevertheless, achieving bridging of a pancreatic stent with an endoscope may prove challenging, particular in cases where the pancreatic duct is completely disconnected. A separate investigation demonstrated high effectiveness of transpapillary drainage and clinical success observed in 86.7%. The methodology employed in the study involved deploying the proximal ends of stents in close proximity to or within the disruption, when bridging was not a viable option for any patient [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. So, in our study, technical success was defined as that.\u003c/p\u003e \u003cp\u003eThe aforementioned studies exhibited limitations, including a focus solely on patients who successfully underwent transpapillary drainage, without thorough analysis of those who failed to undergo the procedure. In our study, a subset of patients (20 out of 63, or 31.7%) did not successfully complete the entire procedure. After comparing the clinical and interventional characteristics, it was established that the performance of endoscopic transpapillary drainage during the advanced stage of the disease may reduce the likelihood of successful prosthesis implantation. This could be attributed to the development of stenosis and obstruction in the pancreatic duct due to long-term treatment of acute necrotizing pancreatitis, resulting in difficulty for a guidewire to pass through. Therefore, we established a 90-day threshold for the interval between the onset of acute pancreatitis and the implementation of trans-papillary drainage. The percentages of patients with intervals of less than 90 days in the two groups were 58.14% (Technical success group) and, 20.00% (Technical failure group) respectively (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011). Further multivariable logistic regression analysis indicated a statistically significant association between the technical success rate within 90 days of onset. The findings suggested that performing transpapillary drainage earlier, specifically within 90 days of symptom onset, may enhance the success rate of prosthesis insertion. Moreover, delayed diagnosis due to insufficient awareness of the disease, coupled with prolonged reliance on conservative treatments such as medication and extended observation periods, can lead to postponed endoscopic intervention (\u0026gt;\u0026thinsp;90 days), potentially raising the risk of technical complications in transpapillary drainage procedures.\u003c/p\u003e \u003cp\u003eNevertheless, the utilization of trans-papillary drainage is associated with several limitations, including the potential risk of infection in a previously sterile collection. A prospective randomized study has been initiated to assess the feasibility and safety of prophylactic pancreatic duct stenting in cases of acute necrotizing pancreatitis, in comparison to conservative treatment. Patients assigned to the intervention group are scheduled to undergo ERCP as promptly as possible, ideally within the first week following the onset of symptoms [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The study was halted prematurely on ethical grounds due to a higher incidence of infection among patients with successful pancreatic duct prosthesis placement (5/5, 100%) compared to those in the conservative treatment group (3/13, 23.1%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01). Therefore, early implementation of endoscopic trans-papillary drainage for patients with acute pancreatitis is not advisable. In addition, the diagnosis of pancreatic duct injury manifested as pancreatic fistula can be challenging, as radiological changes indicating peri-pancreatic local complications are often indistinct during the initial stages of acute necrotizing pancreatitis (\u0026lt;\u0026thinsp;2 weeks) as the disease and necrosis progress. However, by the 2-week mark, computed tomography typically reveals identifiable changes indicative of pancreatic duct disruption or pancreatic fistula [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Considering the risk of early infection and the fact that pancreatic fistula can only be indicated by imaging after 2 weeks, we recommend performing ERCP after 2 weeks.\u003c/p\u003e \u003cp\u003eThe location of MPD injury was also an important factor affecting the technical success, with a higher success rate when the injury occurred in areas other than the head and neck of the pancreas. The injuries near the pancreatic head and neck were more likely to cause distortion and deformation of the duodenum, which further lead to difficulties in intubation; on the other hand, such injuries are more prone to form submucosal scars and pancreatic duct distortion. During the operation, it is difficult for the incision knife and guide wire to enter, and the stent was hard to fix with poor adhesion, thus failing to achieve a good drainage.\u003c/p\u003e \u003cp\u003eFurther analysis was performed on the outcomes, including the removal time of the last drainage tube and the survival status of patients. This study suggested it is beneficial in reducing the catheter indwelling duration. Statistically significant difference in mortality between the two groups was not observed. Patients suffering from severe acute pancreatitis exhibit an increased likelihood of requiring long-term placement of a peripancreatic drainage tube as a consequence of their condition. This necessity is particularly pronounced in patients who develop infections or pancreatic fistulas, where the insertion of a drainage tube becomes imperative. However, the duration of tube indwelling is different for each patient. The main factors affecting the indwelling time of drainage tubes included the patient's nutritional status, the properties and volume of drainage fluid, and the severity of disease. Wearing a tube for a long time can cause many consequences, including pain, infection, granulation hyperplasia, tube breakage, displacement, blockage, and sinus bleeding. Our study selected patients with severe pancreatitis who had been highly suspected of pancreatic duct injury by imaging, and the time span was large. The influence factors between the technical successful group and the technical failed group were analyzed. It is found that in patients with severe pancreatitis complicated with pancreatic duct injury, MPD injury occurred in areas other than the head and neck of the pancreas and ERCP performed within 90 days showed a high success rate, which can significantly shorten the time of drainage tube and improve the quality of life of patients.\u003c/p\u003e \u003cp\u003eStudy limitations include its retrospective design, a small number of cases included, and the difficulty in studying large patient cohorts due to the low incidence of pancreatic fistula. A single-center study may have selection bias.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study explores the occurrence of MPD and highlights the high success rate associated with earlier (\u0026lt;\u0026thinsp;90 days) endoscopic transpapillary drainage and MPD injury occurred in areas other than the head and neck of the pancreas, which could shorten indwelling time of the drainage tube and improve the patients' quality of life.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e \u003cp\u003e All procedures were performed in accordance with the ethical standards of the institutional committee. Written informed consent was obtained from all participants in the study. The study protocol received approval from the Jinling Hospital Ethics Committee and adheres to the principles outlined in the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eAll data in this publication are presented in an entirely anonymized manner. No individual patient details that could compromise privacy are disclosed.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZhijun Su participated in data collection, statistical analysis, writing-original draft, supervision; Xiang Li participated in data curation, writing-review and editing, supervision; Xiaojia Xiao participated in data collection, follow-up; Bo Ye participated in data curation, methodology, supervision; Zhihui Tong participated in methodology, supervision; Weiqin Li participated in methodology, writing-review and editing, supervision.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIannuzzi JP, King JA, Leong JH, et al. Global Incidence of Acute Pancreatitis Is Increasing Over Time: A Systematic Review and Meta-Analysis. Gastroenterology. 2022;162(1):122\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeery AF, Crockett SD, Murphy CC, et al. Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2018. Gastroenterology. 2019;156(1):254\u0026ndash;e7211.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeery AF, Murphy CC, Anderson C, et al. Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2024. Gastroenterology. 2025;168(5):1000\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSikora SS, Khare R, Srikanth G, et al. External pancreatic fistula as a sequel to management of acute severe necrotizing pancreatitis. 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Disconnected pancreatic duct syndrome: diagnostic and therapeutic challenges and future directions. Expert Rev Gastroenterol Hepatol. 2024;18(10):631\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarsen M, Kozarek R. Management of pancreatic ductal leaks and fistulae. J Gastroenterol Hepatol. 2014;29(7):1360\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeierhofer C, Fuegger R, Biebl M et al. Pancreatic Fistulas: Current Evidence and Strategy-A Narrative Review. J Clin Med 2023; 12(15).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen Y, Jiang Y, Qian W, et al. Endoscopic transpapillary drainage in disconnected pancreatic duct syndrome after acute pancreatitis and trauma: long-term outcomes in 31 patients. BMC Gastroenterol. 2019;19(1):54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYokoi Y, Kikuyama M, Kurokami T, et al. Early dual drainage combining transpapillary endotherapy and percutaneous catheter drainage in patients with pancreatic fistula associated with severe acute pancreatitis. Pancreatology. 2016;16(4):497\u0026ndash;507.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmoczynski M, Jagielski M, Jablonska A, et al. Transpapillary drainage of walled-off pancreatic necrosis - a single center experience. Wideochir Inne Tech Maloinwazyjne. 2016;10(4):527\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarjula H, Saarela A, Vaarala A, et al. Endoscopic transpapillary stenting for pancreatic fistulas after necrosectomy with necrotizing pancreatitis. Surg Endosc. 2015;29(1):108\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJagielski M, Smoczynski M, Adrych K. Transpapillary drainage of pancreatic parenchymal necrosis. Wideochir Inne Tech Maloinwazyjne. 2015;10(3):491\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBakker OJ, van Baal MC, van Santvoort HC, et al. Endoscopic transpapillary stenting or conservative treatment for pancreatic fistulas in necrotizing pancreatitis: multicenter series and literature review. Ann Surg. 2011;253(5):961\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRana SS, Bhasin DK, Nanda M, et al. Endoscopic transpapillary drainage for external fistulas developing after surgical or radiological pancreatic interventions. J Gastroenterol Hepatol. 2010;25(6):1087\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhasin DK, Rana SS, Udawat HP, et al. Management of multiple and large pancreatic pseudocysts by endoscopic transpapillary nasopancreatic drainage alone. Am J Gastroenterol. 2006;101(8):1780\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaradarajulu S, Noone TC, Tutuian R, et al. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc. 2005;61(4):568\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeng Y, Ding J, Tian C, et al. Endoscopic transpapillary drainage for walled-off pancreatic necrosis with complete main pancreatic duct disruption by metallic stent placement: A retrospective study. Front Med (Lausanne). 2022;9:1064463.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNi J, Peng K, Yu L, et al. Transpapillary Stenting Improves Treatment Outcomes in Patients Undergoing Endoscopic Transmural Drainage of Ductal Disruption-Associated Pancreatic Fluid Collections. Am J Gastroenterol. 2023;118(6):972\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBanks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis\u0026ndash;2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMederos MA, Reber HA, Girgis MD. Acute Pancreatitis: Rev JAMA. 2021;325(4):382\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrikudanathan G, Yazici C, Evans Phillips A, et al. Diagnosis Manage Acute Pancreat Gastroenterol. 2024;167(4):673\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. 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Prophylactic pancreatic duct stenting in severe acute necrotizing pancreatitis: a prospective randomized study. Endoscopy. 2019;51(11):1027\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarsen M, Kozarek RA. Management of Disconnected Pancreatic Duct Syndrome. Curr Treat Options Gastroenterol. 2016;14(3):348\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute necrotizing pancreatitis, Main pancreatic duct injury, Endoscopic retrograde cholangiopancreatography, Transpapillary drainage","lastPublishedDoi":"10.21203/rs.3.rs-8010012/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8010012/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTrans-papillary therapy remains a critical treatment modality for main pancreatic duct (MPD) injury subsequent to acute necrotizing pancreatitis. This study aimed to verify the factors linked to the technical success of transpapillary drainage by Endoscopic retrograde cholangiopancreatography (ERCP) in managing the MPD injury, and the impact of technical success on the tube duration and overall survival.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted on patients who underwent ERCP procedures for MPD injuries following acute pancreatitis from May 2019 to April 2021. Univariate and multivariate logistic regression analyses were employed to identify factors associated with successful treatment. Kaplan-Meier curves were used to analyze the impact of technical success on the tube duration and overall survival rate of patients.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe included 63 patients in whom the MPD opacification was achieved (43 technical succeed and 20 failed). The successful groups exhibited a higher percentage of interval from onset of acute pancreatitis to the endoscopic trans-papillary drainage procedure (IOP) less than 90 days (58.14%) compared to the failed group (20.00%) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005). This study indicated a statistically significant association between the success rate of endoscopic trans-papillary drainage procedure with IOP less than 90 days (95% CI: 0.06\u0026ndash;0.91, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036) and MPD injury occurred in areas other than the head and neck of the pancreas (95% CI: 1.10-19.77, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.036). Technical successful group (median TD time: 10.3 months, 95% CI: 7.3\u0026ndash;13.3) shorten the tube indwelling time compared with technical failed group (median TD time: 16.8 months, 95% CI: 12.3\u0026ndash;21.3) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.025).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eERCP should be performed within 90 days in patients with MPD injury, and has a higher success rate with injury occurred in areas other than the head and neck of the pancreas. The technical success could shorten indwelling time of the drainage tube and improve patients' life quality.\u003c/p\u003e","manuscriptTitle":"Timing and location are keys: ERCP success and its benefit in MPD injury post-acute pancreatitis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-30 09:16:36","doi":"10.21203/rs.3.rs-8010012/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d5830da-e7d0-48fb-af8a-90bb61febed3","owner":[],"postedDate":"December 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-03T06:58:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-30 09:16:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8010012","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8010012","identity":"rs-8010012","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}