1
|
Malik S, Ullah H, Loganathan P, Singh Dahiya D, Chandan S, Mohan BP, Adler DG. Efficacy of Endoscopic Therapy in Symptomatic Pancreatic Divisum: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2024:00004836-990000000-00273. [PMID: 38457418 DOI: 10.1097/mcg.0000000000001986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/31/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND AND AIMS Pancreas divisum (PD) is a congenital malformation of the pancreas and is implicated as a cause of pancreatitis. The role of endotherapy has been variable in symptomatic PD indicated by recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic pancreatic-type abdominal pain (PP). The aim of this study was to analyze the pooled data to determine the success of endoscopic intervention for pancreas divisum. METHODS We conducted a comprehensive search of several databases (inception to July 2023) to identify studies reporting on the use of endoscopic therapy in symptomatic pancreatic divisum. The random-effects model was used to calculate the pooled rates and I2% values were used to assess the heterogeneity. RESULTS A total of 27 studies were retrieved that reported endoscopic intervention in pancreatic divisum. The calculated pooled rate of technical success was 92% (95% CI: 87-95; I2=63%). The calculated pooled rate of clinical success was 65% (95% CI: 60-70; I2=60%). The rate of clinical success by PD subtypes was highest in RAP at 71% (95% CI: 65-76; I2=24%). Available studies had significant heterogeneity in defining clinical success. The rate of adverse events was 71% (95% CI: 65-76; I2=24%). CONCLUSIONS The role of endoscopic therapy in pancreatic divisum is variable with the highest success rate in recurrent acute pancreatitis. Endoscopic intervention is associated with a higher-than-usual rate of adverse events, including post-ERCP pancreatitis.
Collapse
Affiliation(s)
- Sheza Malik
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Hamid Ullah
- Department of Internal Medicine, Hamid Ullah, West Virginia University Priyadarshini Loganathan, UT Health, San Antonio, TX
| | - Priyadarshini Loganathan
- Department of Internal Medicine, Hamid Ullah, West Virginia University Priyadarshini Loganathan, UT Health, San Antonio, TX
| | | | - Saurabh Chandan
- Department of Gastroenterology, CHI Creighton Medical Center, Omaha, NE
| | - Babu P Mohan
- Department of Gastroenterology, Orlando Gastroenterology PA, Orlando, FL
| | - Douglas G Adler
- Gastroenterology & Hepatology,Center for Advanced Therapeutic Endoscopy at Porter Adventist Hospital in Denver, CO
| |
Collapse
|
2
|
Zhu JH, Zhao SL, Kang Q, Zhu Y, Liu LX, Zou H. Classification of anatomical morphology of cystic duct and its association with gallstone. World J Gastrointest Surg 2024; 16:307-317. [PMID: 38463380 PMCID: PMC10921219 DOI: 10.4240/wjgs.v16.i2.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/20/2023] [Accepted: 01/16/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Gallstones are common lesions that often require surgical intervention. Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones. Preoperatively, the anatomical morphology of the cystic duct (CD), needs to be accurately recognized, especially when anatomical variations occur in the CD, which is otherwise prone to bile duct injury. However, at present, there is no optimal classification system for CD morphology applicable in clinical practice, and the relationship between anatomical variations in CDs and gallstones remains to be explored. AIM To create a more comprehensive clinically applicable classification of the morphology of CD and to explore the correlations between anatomic variants of CD and gallstones. METHODS A total of 300 patients were retrospectively enrolled from October 2021 to January 2022. The patients were divided into two groups: The gallstone group and the nongallstone group. Relevant clinical data and anatomical data of the CD based on magnetic resonance cholangiopancreatography (MRCP) were collected and analyzed to propose a morphological classification system of the CD and to explore its relationship with gallstones. Multivariate analysis was performed using logistic regression analyses to identify the independent risk factors using variables that were significant in the univariate analysis. RESULTS Of the 300 patients enrolled in this study, 200 (66.7%) had gallstones. The mean age was 48.10 ± 13.30 years, 142 (47.3%) were male, and 158 (52.7%) were female. A total of 55.7% of the patients had a body mass index (BMI) ≥ 24 kg/m2. Based on the MRCP, the CD anatomical typology is divided into four types: Type I: Linear, type II: n-shaped, type III: S-shaped, and type IV: W-shaped. Univariate analysis revealed differences between the gallstone and nongallstone groups in relation to sex, BMI, cholesterol, triglycerides, morphology of CD, site of CD insertion into the extrahepatic bile duct, length of CD, and angle between the common hepatic duct and CD. According to the multivariate analysis, female, BMI (≥ 24 kg/m2), and CD morphology [n-shaped: Odds ratio (OR) = 10.97, 95% confidence interval (95%CI): 5.22-23.07, P < 0.001; S-shaped: OR = 4.43, 95%CI: 1.64-11.95, P = 0.003; W-shaped: OR = 7.74, 95%CI: 1.88-31.78, P = 0.005] were significantly associated with gallstones. CONCLUSION The present study details the morphological variation in the CD and confirms that CD tortuosity is an independent risk factor for gallstones.
Collapse
Affiliation(s)
- Jia-Hai Zhu
- Department of Hepatobiliary Pancreatic Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming 650106, Yunnan Province, China
| | - Song-Ling Zhao
- Department of Hepatobiliary Pancreatic Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming 650106, Yunnan Province, China
| | - Qiang Kang
- Department of Hepatobiliary Pancreatic Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming 650106, Yunnan Province, China
| | - Ya Zhu
- Department of Hepatobiliary Pancreatic Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming 650106, Yunnan Province, China
| | - Li-Xin Liu
- Department of Hepatobiliary Pancreatic Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming 650106, Yunnan Province, China
| | - Hao Zou
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Kunming Medical University, Kunming 650106, Yunnan Province, China
| |
Collapse
|
3
|
Inamdar S, Cote GA, Yadav D. Endotherapy for Pancreas Divisum. Gastrointest Endosc Clin N Am 2023; 33:789-805. [PMID: 37709411 DOI: 10.1016/j.giec.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pancreas divisum (PD) is a common anatomic variant of the pancreatic duct. Causal association between PD and pancreatitis has been debated for many years. Minor papilla sphincterotomy (miES) is offered in clinical practice to patients with idiopathic acute recurrent pancreatitis (iRAP) and PD. However, available data originate mainly from observational studies with many limitations. An ongoing international, multicenter, sham-controlled trial is evaluating the efficacy of miES in iRAP and PD. Endoscopic therapy for pain relief has limited to no benefit in patients with chronic abdominal pain or chronic pancreatitis who have PD and is not recommended.
Collapse
Affiliation(s)
- Sumant Inamdar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences, Shorey Building, 8th Floor, 4301 West Markham Street, Little Rock, AR 72205, USA.
| | - Gregory A Cote
- Division of Gastroenterology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mail Code L461, Portland, OR, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburg Medical Center, 200 Lothrop Street, M2, C-wing, Pittsburgh, PA 15213, USA
| |
Collapse
|
4
|
Beyer G, Kasprowicz F, Hannemann A, Aghdassi A, Thamm P, Volzke H, Lerch MM, Kühn JP, Mayerle J. Definition of age-dependent reference values for the diameter of the common bile duct and pancreatic duct on MRCP: a population-based, cross-sectional cohort study. Gut 2023; 72:1738-1744. [PMID: 36828626 PMCID: PMC10423481 DOI: 10.1136/gutjnl-2021-326106] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 02/13/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVE Changes of the pancreaticobiliary ducts herald disease. Magnetic resonance cholangiopancreatography (MRCP) allows accurate duct visualisation. Data on reliable upper reference ranges are missing. DESIGN Cross-sectional whole body MRI data from the population-based Study of Health in Pomerania were analysed. The width of the common bile duct (CBD) and the pancreatic duct (PD) was determined. We aimed to describe the distribution of physiological duct diameters on MRCP in a population of healthy subjects and to identify factors influencing duct size. RESULTS After excluding pre-existing pancreaticobiliary conditions, CBD and PD diameters from 938 and 774 healthy individuals, respectively, showed a significant increase with age (p<0.0001) and exceeded the conventional upper reference limit of normal in 10.9% and 18.2%, respectively. Age-dependent upper reference limits of duct diameters were delineated with non-parametric quantile regression, defined as 95th percentile: for CBD up to 8 mm in subjects <65 years and up to 11 mm in subjects ≥65 years. For the PD reference diameters were up to 3 mm in subjects <65 years and up to 4 mm in subjects ≥65 years. CONCLUSIONS This is the first population-based study delineating age-adjusted upper reference limits of CBD and PD on MRCP. We showed that up to 18.2% of healthy volunteers would have needed diagnostic workup, if the conventional reference values were used. The utilisation of the adapted reference levels may help to avoid unnecessary investigations and thus to reduce healthcare expenditure and test-related adverse events.
Collapse
Affiliation(s)
- Georg Beyer
- Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Florian Kasprowicz
- Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
- Department of Medicine A, University Medicine Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
| | - Anke Hannemann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
- Partner Site Greifswald, German Centre for Cardiovascular Research (DZHK), Greifswald, Germany
| | - Ali Aghdassi
- Department of Medicine A, University Medicine Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
| | - Patrick Thamm
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
| | - Henry Volzke
- Partner Site Greifswald, German Centre for Cardiovascular Research (DZHK), Greifswald, Germany
- Institute for Community Medicine, Clinical Epidemiology, University Medicine Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
| | - Markus M Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
- University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jens-Peter Kühn
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
- Institute and Policlinic of Diagnostic and Interventional Radiology, Medical University, Carl-Gustav-Carus, Dresden, Sachsen, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
- Department of Medicine A, University Medicine Greifswald, Greifswald, Mecklenburg-Vorpommern, Germany
| |
Collapse
|
5
|
Talat A, DeVore Z, Hebda N, Anderson S, Abdelfattah A, Rau P, Hanscom M, Marya NB. EUS-guided rendezvous technique for pancreas divisum. VideoGIE 2023; 8:162-164. [PMID: 37095839 PMCID: PMC10122073 DOI: 10.1016/j.vgie.2022.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
Abstract
Video 1EUS-guided rendezvous technique for pancreas divisum.
Collapse
|
6
|
Kamisawa T. Regression of the ventral and dorsal pancreatic duct. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 30:417-418. [PMID: 36321196 DOI: 10.1002/jhbp.1261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/30/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine Tokyo Metropolitan Komagome, Hospital Tokyo Japan
| |
Collapse
|
7
|
Strand DS, Law RJ, Yang D, Elmunzer BJ. AGA Clinical Practice Update on the Endoscopic Approach to Recurrent Acute and Chronic Pancreatitis: Expert Review. Gastroenterology 2022; 163:1107-1114. [PMID: 36008176 DOI: 10.1053/j.gastro.2022.07.079] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/08/2022] [Accepted: 07/01/2022] [Indexed: 02/07/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Clinical Practice Update Expert Review is to provide practical, evidence-based guidance to clinicians regarding the role of endoscopy for recurrent acute and chronic pancreatitis. METHODS This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide guidance on a topic of clinical importance to the AGA membership, underwent internal peer review by the Clinical Practice Updates Committee (CPUC), and external peer review through standard procedures of Gastroenterology. This review is framed around the 8 best practice advice points agreed upon by the authors, based on the results of randomized controlled trials, observational studies, systematic reviews and meta-analyses, as well expert consensus in this field. Best Practice Advice Statements BEST PRACTICE ADVICE 1: After an unrevealing initial evaluation, endoscopic ultrasound is the preferred diagnostic test for unexplained acute and recurrent pancreatitis. Magnetic resonance imaging with contrast and cholangiopancreatography is a reasonable complementary or alternative test to endoscopic ultrasound, based on local expertise and availability. BEST PRACTICE ADVICE 2: The role of endoscopic retrograde cholangiopancreatography (ERCP) for reducing the frequency of acute pancreatitis episodes in patients with pancreas divisum is controversial, but minor papilla endotherapy may be considered, particularly for those with objective signs of outflow obstruction, such as a dilated dorsal pancreatic duct and/or santorinicele. There is no role for ERCP to treat pain alone in patients with pancreas divisum. BEST PRACTICE ADVICE 3: The role of ERCP for reducing the frequency of pancreatitis episodes in patients with unexplained recurrent acute pancreatitis and standard pancreatic ductal anatomy is controversial and should only be considered after a comprehensive discussion of the uncertain benefits and potentially severe procedure-related adverse events. When pursued, ERCP with biliary sphincterotomy alone may be preferable to dual sphincterotomy. BEST PRACTICE ADVICE 4: Surgical intervention should be considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis. Endoscopic intervention is a reasonable alternative to surgery for suboptimal operative candidates or those who favor a less invasive approach, assuming they are clearly informed that the best practice advice primarily favors surgery. BEST PRACTICE ADVICE 5: When ERCP is pursued, small (≤5mm) main pancreatic duct stones can be treated with pancreatography and conventional stone extraction maneuvers. For larger stones, extracorporeal shockwave lithotripsy and/or pancreatoscopy with intraductal lithotripsy may be required. BEST PRACTICE ADVICE 6: When ERCP is pursued, prolonged stent therapy (6-12 months) is effective for treating symptoms and remodeling main pancreatic duct strictures. The preferred approach is to place and sequentially add multiple plastic stents in parallel (upsizing); emerging evidence suggests that fully covered self-expanding metal stents may have a role for this indication, but additional research is necessary. BEST PRACTICE ADVICE 7: ERCP with stent insertion is the preferred treatment for benign biliary stricture due to chronic pancreatitis. FCSEMS placement is favored over multiple plastic stents whenever feasible, given similar efficacy but significantly reduced need for stent exchange procedures during the treatment course. BEST PRACTICE ADVICE 8: Celiac plexus block should not be routinely performed for the management of pain due to chronic pancreatitis. The decision to proceed with celiac plexus block in selected patients with debilitating pain in whom other therapeutic measures have failed can be considered on a case-by-case basis, but only after discussion of the unclear outcomes of this intervention and its procedural risks.
Collapse
Affiliation(s)
- Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia
| | - Ryan J Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida.
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
8
|
Johansson K, Mustonen H, Seppänen H, Lehtimäki TE. Anatomical pancreatic variants in intraductal papillary mucinous neoplasm patients: a cross-sectional study. BMC Gastroenterol 2022; 22:394. [PMID: 35989322 PMCID: PMC9394057 DOI: 10.1186/s12876-022-02465-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background No previous studies have examined the possible relationship between intraductal papillary mucinous neoplasm (IPMN) and the developmental ductal variations of the pancreas, such as an ansa pancreatica and a meandering main pancreatic duct (MMPD). Methods This retrospective cross-sectional study enrolled 214 patients, 108 with IPMN disease and 106 subjects from a community at the tertiary care unit. The main pancreatic duct (MPD) was evaluated in the head of the pancreas by its course, which were non-MMPD: descending, vertical, and sigmoid, or MMPD including loop types, reverse-Z subtypes, and an N-shape, which was identified for the first time in this study. IPMN patients were also evaluated for worrisome features (WF) or high-risk stigmata (HRS), and the extent of IPMN cysts. Results Among IPMN patients, 18.4% had MMPD, which we observed in only 3.0% of the control group (P < 0.001). Patients with MMPD were more likely to belong to the IPMN group compared with non-MMPD patients [odds ratio (OR) 6.4, 95% confidence interval (CI) 2.2–24.9]. Compared with a descending shape MPD, IPMN patients with an N-shaped MPD were more likely to have a cystic mural nodule (OR 5.9, 95% CI 1.02–36.0). The presence of ansa pancreatica associated with more extent IPMN disease (OR 12.8, 95% CI 2.6–127.7). Conclusions IPMN patients exhibited an MMPD more often than control patients. Ansa pancreatica associated with multiple cysts. Furthermore, an N-shape in IPMN patients associated with cystic mural nodules, suggesting that this shape serves as a risk factor for more severe IPMN. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02465-w.
Collapse
|
9
|
Epidemiological Factors Associated With Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Dual Center Case-Control Study. Pancreas 2022; 51:250-255. [PMID: 35584382 DOI: 10.1097/mpa.0000000000002007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The present study aimed to identify epidemiological factors associated with the development of intraductal papillary mucinous neoplasms (IPMN) of the pancreas comparing patients after IPMN resection with population-based controls. METHODS Preoperative data of 811 patients undergoing pancreatic resection for IPMN were matched in a 1:1 ratio with a random sample of volunteers from the Study of Health in Pomerania, which showed no pancreatic cyst greater than 2 mm in magnetic resonance cholangiopancreaticography. RESULTS A total of 811 controls with a mean age of 61.9 years (standard deviation, 8.4 years) were matched to cases with a mean age of 66.1 years (standard deviation, 9.3 years). A previous history of pancreatitis, endocrine pancreatic insufficiency was significantly more frequent in IPMN patients compared with controls (P = 0.001). Moreover, adjusted data revealed that urogenital cancer (P = 0.034), colorectal cancer (P = 0.021), as well as first-degree family history of colorectal cancer (P = 0.001) were significantly more frequent in IPMN patients. CONCLUSIONS A history of urogenital and colorectal cancer often coincides with IPMN, which have an indication for surgery and are associated with preoperative episodes of pancreatitis and with endocrine insufficiency. Prospective studies are needed to investigate the role of these factors in IPMN development.
Collapse
|
10
|
Hosten N, Bülow R, Völzke H, Domin M, Schmidt CO, Teumer A, Ittermann T, Nauck M, Felix S, Dörr M, Markus MRP, Völker U, Daboul A, Schwahn C, Holtfreter B, Mundt T, Krey KF, Kindler S, Mksoud M, Samietz S, Biffar R, Hoffmann W, Kocher T, Chenot JF, Stahl A, Tost F, Friedrich N, Zylla S, Hannemann A, Lotze M, Kühn JP, Hegenscheid K, Rosenberg C, Wassilew G, Frenzel S, Wittfeld K, Grabe HJ, Kromrey ML. SHIP-MR and Radiology: 12 Years of Whole-Body Magnetic Resonance Imaging in a Single Center. Healthcare (Basel) 2021; 10:33. [PMID: 35052197 PMCID: PMC8775435 DOI: 10.3390/healthcare10010033] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 12/16/2022] Open
Abstract
The Study of Health in Pomerania (SHIP), a population-based study from a rural state in northeastern Germany with a relatively poor life expectancy, supplemented its comprehensive examination program in 2008 with whole-body MR imaging at 1.5 T (SHIP-MR). We reviewed more than 100 publications that used the SHIP-MR data and analyzed which sequences already produced fruitful scientific outputs and which manuscripts have been referenced frequently. Upon reviewing the publications about imaging sequences, those that used T1-weighted structured imaging of the brain and a gradient-echo sequence for R2* mapping obtained the highest scientific output; regarding specific body parts examined, most scientific publications focused on MR sequences involving the brain and the (upper) abdomen. We conclude that population-based MR imaging in cohort studies should define more precise goals when allocating imaging time. In addition, quality control measures might include recording the number and impact of published work, preferably on a bi-annual basis and starting 2 years after initiation of the study. Structured teaching courses may enhance the desired output in areas that appear underrepresented.
Collapse
Affiliation(s)
- Norbert Hosten
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, 17475 Greifswald, Germany; (N.H.); (R.B.); (M.D.); (K.H.); (C.R.)
| | - Robin Bülow
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, 17475 Greifswald, Germany; (N.H.); (R.B.); (M.D.); (K.H.); (C.R.)
| | - Henry Völzke
- Institute for Community Medicine, University Medicine Greifswald, 17475 Greifswald, Germany; (H.V.); (C.O.S.); (A.T.); (T.I.); (W.H.); (J.-F.C.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 10785 Berlin, Germany; (M.N.); (S.F.); (M.D.); (M.R.P.M.); (U.V.); (N.F.); (S.Z.); (A.H.)
| | - Martin Domin
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, 17475 Greifswald, Germany; (N.H.); (R.B.); (M.D.); (K.H.); (C.R.)
| | - Carsten Oliver Schmidt
- Institute for Community Medicine, University Medicine Greifswald, 17475 Greifswald, Germany; (H.V.); (C.O.S.); (A.T.); (T.I.); (W.H.); (J.-F.C.)
| | - Alexander Teumer
- Institute for Community Medicine, University Medicine Greifswald, 17475 Greifswald, Germany; (H.V.); (C.O.S.); (A.T.); (T.I.); (W.H.); (J.-F.C.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 10785 Berlin, Germany; (M.N.); (S.F.); (M.D.); (M.R.P.M.); (U.V.); (N.F.); (S.Z.); (A.H.)
| | - Till Ittermann
- Institute for Community Medicine, University Medicine Greifswald, 17475 Greifswald, Germany; (H.V.); (C.O.S.); (A.T.); (T.I.); (W.H.); (J.-F.C.)
| | - Matthias Nauck
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 10785 Berlin, Germany; (M.N.); (S.F.); (M.D.); (M.R.P.M.); (U.V.); (N.F.); (S.Z.); (A.H.)
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Stephan Felix
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 10785 Berlin, Germany; (M.N.); (S.F.); (M.D.); (M.R.P.M.); (U.V.); (N.F.); (S.Z.); (A.H.)
- Department of Internal Medicine B, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Marcus Dörr
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 10785 Berlin, Germany; (M.N.); (S.F.); (M.D.); (M.R.P.M.); (U.V.); (N.F.); (S.Z.); (A.H.)
- Department of Internal Medicine B, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Marcello Ricardo Paulista Markus
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 10785 Berlin, Germany; (M.N.); (S.F.); (M.D.); (M.R.P.M.); (U.V.); (N.F.); (S.Z.); (A.H.)
- Department of Internal Medicine B, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Uwe Völker
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 10785 Berlin, Germany; (M.N.); (S.F.); (M.D.); (M.R.P.M.); (U.V.); (N.F.); (S.Z.); (A.H.)
- Interfaculty Institute of Genetics and Functional Genomics, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Amro Daboul
- Department of Prosthetic Dentistry, Gerodontology and Biomaterials, University Medicine Greifswald, 17475 Greifswald, Germany; (A.D.); (C.S.); (T.M.); (S.S.); (R.B.)
| | - Christian Schwahn
- Department of Prosthetic Dentistry, Gerodontology and Biomaterials, University Medicine Greifswald, 17475 Greifswald, Germany; (A.D.); (C.S.); (T.M.); (S.S.); (R.B.)
| | - Birte Holtfreter
- Department of Restorative Dentistry, Periodontology, Endodontology, and Preventive and Pediatric Dentistry, University Medicine Greifswald, 17475 Greifswald, Germany; (B.H.); (T.K.)
| | - Torsten Mundt
- Department of Prosthetic Dentistry, Gerodontology and Biomaterials, University Medicine Greifswald, 17475 Greifswald, Germany; (A.D.); (C.S.); (T.M.); (S.S.); (R.B.)
| | - Karl-Friedrich Krey
- Department of Orthodontics, University Medicine Greifswald, 17475 Greifswald, Germany;
| | - Stefan Kindler
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, University Medicine Greifswald, 17475 Greifswald, Germany; (S.K.); (M.M.)
| | - Maria Mksoud
- Department of Oral and Maxillofacial Surgery/Plastic Surgery, University Medicine Greifswald, 17475 Greifswald, Germany; (S.K.); (M.M.)
| | - Stefanie Samietz
- Department of Prosthetic Dentistry, Gerodontology and Biomaterials, University Medicine Greifswald, 17475 Greifswald, Germany; (A.D.); (C.S.); (T.M.); (S.S.); (R.B.)
| | - Reiner Biffar
- Department of Prosthetic Dentistry, Gerodontology and Biomaterials, University Medicine Greifswald, 17475 Greifswald, Germany; (A.D.); (C.S.); (T.M.); (S.S.); (R.B.)
| | - Wolfgang Hoffmann
- Institute for Community Medicine, University Medicine Greifswald, 17475 Greifswald, Germany; (H.V.); (C.O.S.); (A.T.); (T.I.); (W.H.); (J.-F.C.)
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 10785 Berlin, Germany; (M.N.); (S.F.); (M.D.); (M.R.P.M.); (U.V.); (N.F.); (S.Z.); (A.H.)
- German Centre for Neurodegenerative Diseases (DZNE), Partner Site Rostock/Greifswald, 17489 Greifswald, Germany
| | - Thomas Kocher
- Department of Restorative Dentistry, Periodontology, Endodontology, and Preventive and Pediatric Dentistry, University Medicine Greifswald, 17475 Greifswald, Germany; (B.H.); (T.K.)
| | - Jean-Francois Chenot
- Institute for Community Medicine, University Medicine Greifswald, 17475 Greifswald, Germany; (H.V.); (C.O.S.); (A.T.); (T.I.); (W.H.); (J.-F.C.)
| | - Andreas Stahl
- Clinic of Ophthalmology, University Medicine Greifswald, 17475 Greifswald, Germany; (A.S.); (F.T.)
| | - Frank Tost
- Clinic of Ophthalmology, University Medicine Greifswald, 17475 Greifswald, Germany; (A.S.); (F.T.)
| | - Nele Friedrich
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 10785 Berlin, Germany; (M.N.); (S.F.); (M.D.); (M.R.P.M.); (U.V.); (N.F.); (S.Z.); (A.H.)
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Stephanie Zylla
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 10785 Berlin, Germany; (M.N.); (S.F.); (M.D.); (M.R.P.M.); (U.V.); (N.F.); (S.Z.); (A.H.)
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Anke Hannemann
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, 10785 Berlin, Germany; (M.N.); (S.F.); (M.D.); (M.R.P.M.); (U.V.); (N.F.); (S.Z.); (A.H.)
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Martin Lotze
- Functional Imaging Unit, Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, 17475 Greifswald, Germany;
| | - Jens-Peter Kühn
- Institute and Policlinic of Diagnostic and Interventional Radiology, Medical University, Carl-Gustav Carus, 01307 Dresden, Germany;
| | - Katrin Hegenscheid
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, 17475 Greifswald, Germany; (N.H.); (R.B.); (M.D.); (K.H.); (C.R.)
| | - Christian Rosenberg
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, 17475 Greifswald, Germany; (N.H.); (R.B.); (M.D.); (K.H.); (C.R.)
| | - Georgi Wassilew
- Clinic of Orthopedics, University Medicine Greifswald, 17475 Greifswald, Germany;
| | - Stefan Frenzel
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, 17475 Greifswald, Germany; (S.F.); (K.W.); (H.J.G.)
| | - Katharina Wittfeld
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, 17475 Greifswald, Germany; (S.F.); (K.W.); (H.J.G.)
- German Center of Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Site Greifswald, 17489 Greifswald, Germany
| | - Hans J. Grabe
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, 17475 Greifswald, Germany; (S.F.); (K.W.); (H.J.G.)
- German Center of Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Site Greifswald, 17489 Greifswald, Germany
| | - Marie-Luise Kromrey
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, 17475 Greifswald, Germany; (N.H.); (R.B.); (M.D.); (K.H.); (C.R.)
- Correspondence:
| |
Collapse
|
11
|
Cohen RZ, Freeman AJ. Pancreatitis in Children. Pediatr Clin North Am 2021; 68:1273-1291. [PMID: 34736589 DOI: 10.1016/j.pcl.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pediatric pancreatitis describes a spectrum covering acute pancreatitis, acute recurrent pancreatitis, and chronic pancreatitis, each with varying clinical manifestations and risk factors requiring a tailored diagnostic approach. We emphasize management strategies based on age, risk factors, recurrence, and complications. A discussion of the role of therapeutic endoscopy is reviewed and highlights the growing role of endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in children with pancreatitis. Particular diagnostic challenges in autoimmune pancreatitis are reviewed with an emphasis on differentiating this entity from alternate pancreaticobiliary pathologies. Finally, we explore a multidisciplinary approach to acute recurrent and chronic pancreatitis.
Collapse
Affiliation(s)
- Reuven Zev Cohen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road Northeast, Atlanta, GA 30329, USA.
| | - A Jay Freeman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road Northeast, Atlanta, GA 30329, USA
| |
Collapse
|
12
|
Longitudinal Monitoring of Simulated Interstitial Fluid Pressure for Pancreatic Ductal Adenocarcinoma Patients Treated with Stereotactic Body Radiotherapy. Cancers (Basel) 2021; 13:cancers13174319. [PMID: 34503129 PMCID: PMC8430878 DOI: 10.3390/cancers13174319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/03/2021] [Accepted: 08/19/2021] [Indexed: 11/25/2022] Open
Abstract
Simple Summary High vessel permeability, poor perfusion, low lymphatic drainage, and dense abundant stroma elevate interstitial fluid pressures (IFP) in pancreatic ductal adenocarcinoma (PDAC). The present study aims to monitor longitudinal changes in simulated tumor IFP and velocity (IFV) values using a dynamic contrast-enhanced (DCE)-MRI-based computational fluid modeling (CFM) approach in PDAC. Nine PDAC patients underwent DCE-MRI acquisition on a 3-Tesla MRI scanner at pre-treatment (TX (0)), immediately after the first fraction of stereotactic body radiotherapy (SBRT, (D1-TX)), and six weeks post-TX (D2-TX). The partial differential equation of IFP formulated from the continuity equation using the Starling Principle of fluid exchange and Darcy velocity–pressure relationship was solved in COMSOL Multiphysics software to generate IFP and IFV parametric maps using relevant tumor tissue physiological parameters. Initial results suggest that after validation, IFP and IFV can be imaging biomarkers of early response to therapy that may guide precision medicine in PDAC. Abstract The present study aims to monitor longitudinal changes in simulated tumor interstitial fluid pressure (IFP) and velocity (IFV) values using dynamic contrast-enhanced (DCE)-MRI-based computational fluid modeling (CFM) in pancreatic ductal adenocarcinoma (PDAC) patients. Nine PDAC patients underwent MRI, including DCE-MRI, on a 3-Tesla MRI scanner at pre-treatment (TX (0)), after the first fraction of stereotactic body radiotherapy (SBRT, (D1-TX)), and six weeks post-TX (D2-TX). The partial differential equation of IFP formulated from the continuity equation, incorporating the Starling Principle of fluid exchange, Darcy velocity, and volume transfer constant (Ktrans), was solved in COMSOL Multiphysics software to generate IFP and IFV maps. Tumor volume (Vt), Ktrans, IFP, and IFV values were compared (Wilcoxon and Spearman) between the time- points. D2-TX Ktrans values were significantly different from pre-TX and D1-TX (p < 0.05). The D1-TX and pre-TX mean IFV values exhibited a borderline significant difference (p = 0.08). The IFP values varying <3.0% between the three time-points were not significantly different (p > 0.05). Vt and IFP values were strongly positively correlated at pre-TX (ρ = 0.90, p = 0.005), while IFV exhibited a strong negative correlation at D1-TX (ρ = −0.74, p = 0.045). Vt, Ktrans, IFP, and IFV hold promise as imaging biomarkers of early response to therapy in PDAC.
Collapse
|
13
|
de Jong DM, Stassen PM, Poley JW, Fockens P, Timmer R, Voermans RP, Verdonk RC, Bruno MJ, de Jonge PJ. Clinical outcome of endoscopic therapy in patients with symptomatic pancreas divisum: a Dutch cohort study. Endosc Int Open 2021; 9:E1164-E1170. [PMID: 34222643 PMCID: PMC8216775 DOI: 10.1055/a-1460-7899] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/15/2021] [Indexed: 10/28/2022] Open
Abstract
Background and study aims Although the majority of patients with pancreas divisum (PDiv) are asymptomatic, a subgroup present with recurrent pancreatitis or pain for which endoscopic therapy may be indicated. The aim of this study was to evaluate success rates and long-term outcomes of endoscopic treatment in patients with symptomatic PDiv. Patients and methods A multicenter, retrospective cohort study was performed. Patients with symptomatic PDiv presenting with recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), or chronic abdominal pancreatic-type pain (CAP) who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2000 and December 2019 were included. The primary outcome was clinical success, defined as either no recurrent episode of acute pancreatitis (AP) for RAP patients, no flares for CP patients, or absence of abdominal pain for patients with CAP after technically successful ERCP. Results In 60 of 81 patients (74.1 %) a technically successful papilla minor intervention was performed. Adverse events were reported in 30 patients (37 %), with post-ERCP pancreatitis in 18 patients. The clinical success rate for patients with at least 3 months of follow-up was 42.6 %, with higher rates of success among patients presenting with RAP (44.4 %) as compared to those with CP (33.3 %) or CAP (33.3 %). Long-term sustained response was present in 40.9 % of patients with a technically successful intervention. In patients with RAP who did not completely respond to treatment, the mean number of AP episodes after treatment decreased significantly from 3.5 to 1.1 per year, and subsequently the interval between AP episodes increased from 278 to 690 days ( P = 0.0006). A potential predictive factor of failure of clinical success after technically successful ERCP, at univariate analysis, was male sex (OR = 0.25, P = 0.02). Conclusions Endoscopic therapy in patients with symptomatic PDiv is moderately effective, with its highest yield in patients presenting with RAP. Future studies are needed to assess factors predictive for success of endoscopic therapy and potential risk factors for relapse after ERCP.
Collapse
Affiliation(s)
- David M. de Jong
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pauline M. Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jan Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, the Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, the Netherlands
| | - Robert C. Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter J.F. de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
14
|
Mann R, Boregowda U, Vyas N, Gajendran M, Umapathy CP, Sayana H, Echavarria J, Patel S, Saligram S. Current advances in the management of chronic pancreatitis. Dis Mon 2021; 67:101225. [PMID: 34176572 DOI: 10.1016/j.disamonth.2021.101225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.
Collapse
Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, 1303 E Herndon Ave, Fresno, CA 93720, USA
| | - Umesha Boregowda
- Department of Internal Medicine, Bassett Healthcare Network, Columbia Bassett Medical School, 1 Atwell Road, Cooperstown, NY 13326, USA
| | - Neil Vyas
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Science Center El Paso, 2000B Transmountain Road, El Paso, TX 79911, USA
| | - Chandra Prakash Umapathy
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Hari Sayana
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Juan Echavarria
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Sandeep Patel
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Shreyas Saligram
- Department of Gastroenterology and Advanced endoscopy, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
| |
Collapse
|
15
|
Conti Bellocchi MC, Crinò SF, Pin F, di Stefano S, Le Grazie M, Bernardoni L, Ruffini M, Frulloni L, Gabbrielli A. Reappraisal of factors impacting the cannulation rate and clinical efficacy of endoscopic minor papilla sphincterotomy. Pancreatology 2021; 21:805-811. [PMID: 33745788 DOI: 10.1016/j.pan.2021.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/15/2021] [Accepted: 01/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND We aimed to assess factors impacting the endoscopic minor papilla sphincterotomy (EMPS) success rate, clinical efficacy, and safety in a large cohort of patients with symptomatic pancreas divisum (PD). METHODS Retrospective study including patients with PD referred to the Pancreas Institute of Verona from May 2009 to May 2020 to undergo EMPS. The whole population was analyzed to assess EMPS technical success, defined as the rate of deep cannulation of the dorsal duct. Patients treated for recurrent pancreatitis (RP) with a minimum follow-up of 1 year were included to evaluate the clinical efficacy, defined as resolution or significant reduction of acute pancreatitis (AP) episodes. Safety was defined as the rate of procedure-related adverse events (AEs) according to an international lexicon. The effects of the main determinants on study outcomes were evaluated. RESULTS Overall, 106 patients were evaluated. Technical success was obtained in 87 (82.1%). The presence of pancreatic calcifications was associated with failure (p < 0.0001). Clinical efficacy was evaluated in 59 patients. Resolution/reduction of AP episodes after EMPS was observed in 93% of patients over a median follow-up of 49 months (IQR 37-92). Smoking habit was associated with AP recurrence (p = 0.026). The overall AE rate was 14.9%, with post-ERCP pancreatitis as the most common complication (12.6%). CONCLUSIONS In our study, performed at a tertiary center, EMPS showed satisfactory technical success and an acceptable safety profile. If confirmed by prospective multicenter studies, EMPS could become the standard of care for the treatment of RP in PD.
Collapse
Affiliation(s)
- Maria Cristina Conti Bellocchi
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy.
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Federico Pin
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Serena di Stefano
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Marco Le Grazie
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Laura Bernardoni
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Martina Ruffini
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Luca Frulloni
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| | - Armando Gabbrielli
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy
| |
Collapse
|
16
|
Proximal Migration of Pancreatic Duct Stent in Pancreas Divisum: Challenges in Retrieval and Review of the Literature. Case Rep Gastrointest Med 2021; 2021:5531658. [PMID: 33968451 PMCID: PMC8081641 DOI: 10.1155/2021/5531658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/10/2021] [Accepted: 04/13/2021] [Indexed: 11/30/2022] Open
Abstract
Pancreas divisum is the most common congenital malformation of the pancreas. Sometimes it is considered an etiology when patients present with recurrent episodes of pancreatitis. Endoscopic retrograde pancreatography (ERP) with selective cannulation of the minor papilla with sphincterotomy and stent placement are performed in these patients. Proximal migration of pancreatic stents in pancreas divisum is rare and challenging to manage. We describe a case of proximal migration of a pancreatic stent in a patient with pancreas divisum and perform a review of literature.
Collapse
|
17
|
Suzuki M, Minowa K, Isayama H, Shimizu T. Acute recurrent and chronic pancreatitis in children. Pediatr Int 2021; 63:137-149. [PMID: 32745358 DOI: 10.1111/ped.14415] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/27/2020] [Accepted: 07/28/2020] [Indexed: 12/14/2022]
Abstract
Acute recurrent pancreatitis (ARP) is defined as two distinct episodes of acute pancreatitis (AP), whereas chronic pancreatitis (CP) is caused by persistent inflammation of the pancreas. In children they are caused by genetic mutations, autoimmune pancreatitis, congenital pancreatic abnormalities, and other conditions. Acute recurrent pancreatitis is frequently a precursor to CP, and both are thought to be on the same disease continuum. In particular, genetic factors are associated with early progression of ARP to CP. The diagnosis of CP, as in AP, is based on clinical findings, biochemical tests, and imaging studies. Findings of exocrine pancreatic dysfunction are also important in the diagnosis of CP. A step-up strategy has become increasingly standard for the treatment of patients with CP. This strategy starts with endoscopic treatment, such as pancreatic sphincterotomy and stenting, and progresses to surgery should endoscopic therapy fail or prove technically impossible. Non-opioid (e.g. ibuprofen / naproxen) and opioid (e.g. oxycodone) forms of analgesia are widely used in pediatric patients with AP or CP, whereas pancreatic enzyme replacement therapy may be beneficial for patients with abdominal pain, steatorrhea, and malnutrition. Despite the disparity in the age of onset, pediatric CP patients display some similarities to adults in terms of disease progress. To reduce the risk of developing pancreatic exocrine inefficiency, diabetes and pancreatic cancer in the future, clinicians need to be aware of the current diagnostic approach and treatment methods for ARP and CP and refer them to a pediatric gastroenterologist in a timely manner.
Collapse
Affiliation(s)
- Mitsuyoshi Suzuki
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kei Minowa
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| |
Collapse
|
18
|
A New Quantitative Classification of the Extrahepatic Biliary Tract Related to Cystic Duct Implantation. J Gastrointest Surg 2021; 25:2268-2279. [PMID: 33269458 PMCID: PMC8484130 DOI: 10.1007/s11605-020-04852-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/28/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Knowledge regarding biliary anatomy and its variations, including the cystic duct (CD), is important in the pre-surgical setting and for predicting biliary diseases. However, no large series has focused on CD evaluation using a quantitative analysis. The primary aim of this prospective study was to create a 'taxonomic' classification of CD anatomy in a large cohort of subjects who underwent magnetic resonance cholangiopancreatography (MRCP). The secondary aim was to evaluate the correlations between extrahepatic bile duct (EHBD) variants and biliary diseases. METHODS We enrolled patients who underwent MRCP for different clinical indications from January 2017 to May 2019. Demographical, anatomical and clinical data were evaluated using statistical analyses, as appropriate. The anatomical assessment of EHBD was performed using the standard classification for CD in low, medium, and high insertions, and the lengths of CD to the duodenal papilla (DP), and EHBD was determined to conduct a new quantitative analysis. RESULTS The final study population comprised 1004 subjects. A new classification for EHBD as per the percentile distribution of the ratio CDDP/EHBD was designed, and the following categories were obtained: type 1 (below the 25th percentile) for CDDP/EHBD ratio ≤ 50%; type 2 (25th to 75th percentile) for CDDP/EHBD ratio 51-75% and type 3 (above the 75th percentiles) for CDDP/EHBD ratio > 75%. Type 1 of the new classification of CD implantation was significantly superior in terms of the detection of low, medial and intra-pancreatic CD that was significantly correlated with a high risk of choledochal lithiasis in comparison with the standard classification (P < 0.001). CONCLUSIONS The new classification of CD implantation enables identification of the vast majority of intra-pancreatic CDs that are correlated with a high risk of choledochal lithiasis in a single category (type 1) that is easy to identify using imaging.
Collapse
|
19
|
Beyer G, Habtezion A, Werner J, Lerch MM, Mayerle J. Chronic pancreatitis. Lancet 2020; 396:499-512. [PMID: 32798493 DOI: 10.1016/s0140-6736(20)31318-0] [Citation(s) in RCA: 227] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/02/2020] [Accepted: 05/07/2020] [Indexed: 12/15/2022]
Abstract
Chronic pancreatitis is a multifactorial, fibroinflammatory syndrome in which repetitive episodes of pancreatic inflammation lead to extensive fibrotic tissue replacement, resulting in chronic pain, exocrine and endocrine pancreatic insufficiency, reduced quality of life, and a shorter life expectancy. The incidence and prevalence of chronic pancreatitis is rising and no curative treatment is available. Using novel diagnostic algorithms, definitive chronic pancreatitis can be diagnosed by imaging criteria alone, whereas probable chronic pancreatitis requires clinical features and imaging criteria. Criteria for the diagnosis of early chronic pancreatitis are still under discussion and need prospective validation in clinical trials. Cross-sectional imaging should be used first; endoscopic ultrasound is needed only when CT or MRI are inconclusive or to plan therapeutic interventions. Management of chronic pancreatitis requires an interdisciplinary approach including primary care practitioners, gastroenterologists, surgeons, radiologists, pain specialists, and nutritional therapists. Patients with chronic pancreatitis should be seen at least once a year and re-evaluated for causal risk factors, symptom control, and complications such as malnutrition, pancreatic exocrine insufficiency, and diabetes; refer to a specialised centre if symptoms are poorly controlled or there is risk of deterioration. Scoring systems to monitor disease progression have been developed and validated internationally. Interventional treatments for pain or cholestasis should be done by specialists only, and early discussion of treatment approaches should include all medical disciplines involved in care. Throughout this Seminar, we address research needs such as staging of pancreatitis, aspects of malnutrition and pain, and cancer surveillance, to help improve the care of patients.
Collapse
Affiliation(s)
- Georg Beyer
- Medical Department II, University Hospital, LMU Munich, Munich, Germany
| | - Aida Habtezion
- Division of Gastroenterology and Hepatology, Stanford Medicine, Stanford University, Stanford, CA, USA
| | - Jens Werner
- Department of General, Visceral and Transplant Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Markus M Lerch
- Department of Medicine A, University Medicine, University of Greifswald, Greifswald, Germany
| | - Julia Mayerle
- Medical Department II, University Hospital, LMU Munich, Munich, Germany.
| |
Collapse
|
20
|
Dutta S, Sowmiya SV, Chapa UK, Jain A, Reddy A, Nelamangala Ramakrishnaiah VP. Pancreatic divisum with chronic pancreatitis of the ventral pancreas. ANZ J Surg 2020; 91:E126-E127. [PMID: 32648986 DOI: 10.1111/ans.16152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/27/2020] [Accepted: 07/01/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Souradeep Dutta
- Division of GI and HPB Surgery, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sathyamangalam V Sowmiya
- Division of GI and HPB Surgery, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Uday K Chapa
- Division of GI and HPB Surgery, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ankit Jain
- Division of GI and HPB Surgery, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Abhinaya Reddy
- Division of GI and HPB Surgery, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | |
Collapse
|
21
|
Renzulli M, Pagano N, Golfieri R. Pancreas divisum inversus. Clin Anat 2020; 33:646-652. [PMID: 31576611 DOI: 10.1002/ca.23475] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/30/2019] [Accepted: 09/14/2019] [Indexed: 12/26/2022]
Abstract
Pancreatic duct variations are usually diagnosed incidentally, in particular when using magnetic resonance cholangiopancreatography (MRCP), the most accurate imaging modality for depicting the pancreatic ductal system. However, the frequency and the embryologic development of pancreatic variants have not been well investigated. The purpose of this prospective study was to investigate the frequency of pancreatic ductal variants, providing potential explanations of their embryologic basis. The pancreatic ductal anatomies of 202 patients with mean ± standard deviation (SD) age of 54 ± 27 years, 56% females, who underwent MRCP for different indications between April 2018 and March 2019, were prospectively collected. Normal pancreatic ductal variants were identified in 196 cases (97%), and variants of pancreas divisum in six cases (3%). In the type C variant of the normal pancreatic anatomy, found in 3% of the cases, the dorsal duct was joined to the ventral duct while the accessory duct did not communicate with the dorsal duct. Unlike the classic type C variant, in our cases, the accessory pancreatic duct (APD) was long (mean ± SD of 58 ± 8.5 mm) and originated in the lower portion of the pancreatic head, caudally to the duct of Wirsung. This was a new subtype of the type C variant or a new variant, which could be called "pancreas divisum inversus"; the APD could be called the isolated duct of Santorini. Reporting this new variant could increase knowledge regarding the pancreatic anatomy in order to avoid misdiagnosis and to help in better understanding pancreatic diseases and their relative treatment. Clin. Anat., 33:646-652, 2020. © 2019 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Matteo Renzulli
- Radiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Nico Pagano
- Gastroenterology Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| |
Collapse
|
22
|
Dugic A, Nikolic S, Mühldorfer S, Bulajic M, Pozzi Mucelli R, Tsolakis AV, Löhr JM, Vujasinovic M. Clinical importance of main pancreatic duct variants and possible correlation with pancreatic diseases. Scand J Gastroenterol 2020; 55:517-527. [PMID: 32393143 DOI: 10.1080/00365521.2020.1760345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Except for pancreas divisum (PD), the prevalence of anatomic variants of the main pancreatic duct (MPD) seems to be insufficiently investigated. To date, their role in the occurrence of pancreatic exocrine insufficiency (PEI) and morphological changes suggestive of chronic pancreatitis (CP) has remained unclear.Methods: A systematic review was performed, searching MEDLINE and Web of Science, limited to articles published between 1960 and 1 June 2019.Results: Our review included a total number of 3234 subjects. The most common variant of MPD was type 3, followed by type 1, indicating MPD drainage pattern into major papilla (MP) as the most frequent. A sub-variant of type 3, known as 'reverse pancreas divisum' had a prevalence of 2.2%. Type 4 variant- PD, was found in 6.4% of all cases. The most common sub-variant of PD was complete PD, followed by incomplete PD and variant with MPD as only pancreatic duct. Type 5 variant (including ansa pancreatica) was present in 2.9% of subjects. Apart from one study with a significantly higher frequency of morphological changes suggestive of CP in patients with ansa pancreatica, the studies stated no significant association between pancreatic disease and MPD variants. Furthermore, only one study examined the influence of MPD variants on exocrine pancreatic function. Although equivocal, this association is most likely found to be insignificant.Conclusion: To elucidate linkage between MPD variants and the occurrence of chronic pancreatitis and impairment of pancreatic exocrine function, further clinical investigations are warranted.
Collapse
Affiliation(s)
- Ana Dugic
- Department of Internal Medicine, Clinic for Gastroenterology, Endocrinology and Metabolic Disorders, Bayreuth, Germany.,Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Sara Nikolic
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Gastroenterology, Division of Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Steffen Mühldorfer
- Department of Internal Medicine, Clinic for Gastroenterology, Endocrinology and Metabolic Disorders, Bayreuth, Germany
| | - Milutin Bulajic
- Gastroenterology and Digestive Endoscopy Department, Mater Olbia Hospital, Olbia, Italy
| | - Raffaella Pozzi Mucelli
- Department of Abdominal Radiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Apostolos V Tsolakis
- Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Solna (MedS, K2), Division of Clinical Medicine, Karolinska Institute, Stockholm, Sweden
| | - J-Matthias Löhr
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.,Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Miroslav Vujasinovic
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
23
|
Wood CG, Lopes Vendrami C, Craig E, Mittal PK, Miller FH. Pancreatitis in the developmentally anomalous pancreas. Abdom Radiol (NY) 2020; 45:1316-1323. [PMID: 31468154 DOI: 10.1007/s00261-019-02197-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Developmental anomalies of the pancreas include more common entities such as pancreas divisum and annular pancreas, and unusual entities such as heterotopic pancreas. While these anomalies can present a diagnostic challenge to the radiologist, when the pancreatic tissue involved in these processes develops pancreatitis, the radiographic appearance can present a diagnostic dilemma. Awareness of these pancreatic anomalies and familiarity with their appearance when inflamed is necessary to distinguish pancreatitis in the developmentally anomalous pancreas from other inflammatory or neoplastic processes.
Collapse
Affiliation(s)
- Cecil G Wood
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Camila Lopes Vendrami
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Elizabeth Craig
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA
| | - Pardeep K Mittal
- Department of Radiology and Imaging, Medical College of Georgia, 1120 15th Street BA-1411, Augusta, GA, 30912, USA
| | - Frank H Miller
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, 60611, USA.
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N. St. Clair St. Suite 800, Chicago, IL, 60611, USA.
| |
Collapse
|
24
|
Harrington KA, Shukla-Dave A, Paudyal R, Do RKG. MRI of the Pancreas. J Magn Reson Imaging 2020; 53:347-359. [PMID: 32302044 DOI: 10.1002/jmri.27148] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 03/01/2020] [Accepted: 03/02/2020] [Indexed: 02/06/2023] Open
Abstract
MRI has played a critical role in the evaluation of patients with pancreatic pathologies, from screening of patients at high risk for pancreatic cancer to the evaluation of pancreatic cysts and indeterminate pancreatic lesions. The high mortality associated with pancreatic adenocarcinomas has spurred much interest in developing effective screening tools, with MRI using magnetic resonance cholangiopancreatography (MRCP) playing a central role in the hopes of identifying cancers at earlier stages amenable to curative resection. Ongoing efforts to improve the resolution and robustness of imaging of the pancreas using MRI may thus one day reduce the mortality of this deadly disease. However, the increasing use of cross-sectional imaging has also generated a concomitant clinical conundrum: How to manage incidental pancreatic cystic lesions that are found in over a quarter of patients who undergo MRCP. Efforts to improve the specificity of MRCP for patients with pancreatic cysts and with indeterminate pancreatic masses may be achieved with continued technical advances in MRI, including diffusion-weighted and T1 -weighted dynamic contrast-enhanced MRI. However, developments in quantitative MRI of the pancreas remain challenging, due to the small size of the pancreas and its upper abdominal location, adjacent to bowel and below the diaphragm. Further research is needed to improve MRI of the pancreas as a clinical tool, to positively affect the lives of patients with pancreatic abnormalities. This review focuses on various MR techniques such as MRCP, quantitative imaging, and dynamic contrast-enhanced imaging and their clinical applicability in the imaging of the pancreas, with an emphasis on pancreatic malignant and premalignant lesions. Level of Evidence 5 Technical Efficacy Stage 3 J. MAGN. RESON. IMAGING 2021;53:347-359.
Collapse
Affiliation(s)
- Kate A Harrington
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amita Shukla-Dave
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ramesh Paudyal
- Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard K G Do
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
25
|
Powell-Brett S, de Liguori Carino N, Roberts K. Understanding pancreatic exocrine insufficiency and replacement therapy in pancreatic cancer. Eur J Surg Oncol 2020; 47:539-544. [PMID: 32178962 DOI: 10.1016/j.ejso.2020.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/06/2020] [Indexed: 02/08/2023] Open
Abstract
Pancreatic exocrine insufficiency (PEI) is highly prevalent in patients with pancreatic cancer, and has substantial implications for quality of life and survival. Post resection, PEI is associated with increased post-operative complications, longer hospital stays and higher costs. Treatment with pancreatic enzyme replacement therapy (PERT) improves quality of life and confers significant survival advantages. Despite this many patients with pancreatic cancer do not currently receive PERT. The nutritional consequences of PEI are extensive and even more relevant in the elderly owing to age related gastrointestinal tract and pancreatic changes that predispose to malnutrition.
Collapse
Affiliation(s)
- S Powell-Brett
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospital Birmingham, Birmingham, UK.
| | - N de Liguori Carino
- Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary, Manchester University Hospitals Foundation Trust, UK
| | - K Roberts
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospital Birmingham, Birmingham, UK
| |
Collapse
|
26
|
Wang L, Zheng S. Pancreatic senescence and its clinical manifestations. Aging Med (Milton) 2020; 3:48-52. [PMID: 32232192 PMCID: PMC7099748 DOI: 10.1002/agm2.12095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/25/2019] [Accepted: 12/25/2019] [Indexed: 12/19/2022] Open
Abstract
The pancreas is a vital organ which has both endocrine and exocrine functions and plays an essential role in food digestion and glucose metabolism. Pancreatic structure and function undergo a series of changes with aging and senescence. Pancreatic exocrine and endocrine function gradually change, which may lead to conditions such as dyspepsia and diabetes mellitus. Hence, clinicians need to be familiar with the characteristics of pancreatic senescence. This article reviews the manifestations of pancreatic senescence and its significance for clinical practice.
Collapse
Affiliation(s)
- Lu Wang
- Huadong Hospital Affiliated to Fudan UniversityShanghaiChina
| | - Songbai Zheng
- Huadong Hospital Affiliated to Fudan UniversityShanghaiChina
| |
Collapse
|
27
|
Aghdassi AA, Schauer B, Duscha D, Ittermann T, Pickartz T, Budde C, Simon P, Moskwa P, Kromrey ML, Bülow R, Völzke H, Kühn J, Lerch MM. Comparability of size measurements of the pancreas in magnetic resonance imaging and transabdominal ultrasound. Clin Anat 2019; 33:431-439. [PMID: 31883163 DOI: 10.1002/ca.23551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/20/2019] [Accepted: 12/12/2019] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Transabdominal ultrasound (US) and magnetic resonance imaging (MRI) are commonly used for the examination of the pancreas in clinical routine. We therefore were interested in the concordance of these two imaging methods for the size measurement of the pancreas and how age, gender, and body mass index (BMI) affect the organ size. METHODS A total of 342 participants from the Study of Health in Pomerania underwent whole-body MRI and transabdominal US on the same day, and the diameter of the pancreatic head, body, and tail were measured. The agreement between US and MRI measurements was assessed by Bland and Altman plots. Intraclass correlation coefficients were used to compare observers. A multivariable regression model was applied using the independent variables age, gender, and body mass index. RESULTS Compared to MRI, abdominal US returned smaller values for each segment of the pancreas, with a high level of inconsistency between these two methods. The mean difference was 0.39, 0.18, and 0.54 cm for the head, body, and tail, respectively. A high interobserver variability was detected for US. Multivariable analysis showed that pancreatic size in all three segments increased with BMI in both genders whereas pancreatic head and tail size decreased with age, an effect more marked in women. CONCLUSIONS Agreement of pancreatic size measurements is poor between US and MRI. These limitations should be considered when evaluating morphologic features for pathologic conditions or setting limits of normal size. Adjustments for BMI, gender, and age may also be warranted.
Collapse
Affiliation(s)
- Ali A Aghdassi
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Birgit Schauer
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - David Duscha
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Till Ittermann
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Tilman Pickartz
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Christoph Budde
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Peter Simon
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Patryk Moskwa
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Marie L Kromrey
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Robin Bülow
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Henry Völzke
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Jens Kühn
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Markus M Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| |
Collapse
|
28
|
Abstract
Introduction: Pancreas divisum is the most common congenital malformation of the pancreas with the majority asymptomatic. The etiological role, pathogenesis, clinical significance and management of pancreas divisum in pancreatic disease has not been clearly defined and our understanding is yet to be fully elucidated.Areas covered: This review describes the role of pancreas divisum in the development of pancreatic disease and the ambiguity related to it. In our attempt to offer clarity, a comprehensive search on PubMed, Ovid, Embase and Cochrane Library from inception to May 2019 was undertaken using key words "pancreas divisum", "idiopathic recurrent acute pancreatitis" and "chronic pancreatitis".Expert opinion: Current research fails to define a clear association between pancreas divisum and pancreatic disease. Though debatable, several studies do suggest a pathological role of pancreas divisum in pancreatic disease and a benefit of minor papilla therapy in the setting of acute recurrent pancreatitis. Surgical and endoscopic therapeutic modalities have not been directly compared. With the current data available, it would be imprudent to advise a definitive line of management for pancreatic disease associated with pancreas divisum and should involve a comprehensive discussion with the individual patient to define expectations before embarking on any medical and/or interventional therapy.
Collapse
Affiliation(s)
- Aditya Gutta
- Advanced Endoscopy Gastroenterology Fellow, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Indianapolis, IN 46202
| | - Evan Fogel
- Professor of Medicine, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Suite 1602, Indianapolis, IN 46202
| | - Stuart Sherman
- Professor of Medicine, Glen Lehman Professor in Gastroenterology, Indiana University School of Medicine, Division of Gastroenterology, 550 N. University Blvd, Suite 1634, Indianapolis, IN 46202
| |
Collapse
|
29
|
Abstract
INTRODUCTION The significance of pancreas divisum (PD) as a risk factor for pancreatitis is controversial. We analyzed the characteristics of children with PD associated with acute recurrent or chronic pancreatitis to better understand its impact. PATIENTS AND METHODS We compared children with or without PD in the well-phenotyped INSPPIRE (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) cohort. Differences were analyzed using 2-sample t test or Wilcoxon rank sum test for continuous variables, Pearson χ or Fisher exact test for categorical variables. RESULTS PD was found in 52 of 359 (14.5%) subjects, a higher prevalence than the general population (∼7%). Females more commonly had PD (71% vs. 55%; P=0.02). Children with PD did not have a higher incidence of mutations in SPINK1, CFTR, CTRC compared with children with no PD. Children with PD were less likely to have PRSS1 mutations (10% vs. 34%; P<0.01) or a family history of pancreatitis (P<0.05), and more likely to have hypertriglyceridemia (11% vs. 3%; P=0.03). Children with PD underwent significantly more endoscopic procedures and pancreatic sphincterotomy. Patients with PD had fewer attacks of acute pancreatitis (P=0.03) and were less likely to develop exocrine pancreatic insufficiency (P=0.01). Therapeutic endoscopic retrograde cholangiopancreatography was considered most helpful if pancreatic duct was impacted with stones (83% helpful). CONCLUSIONS PD is likely a risk factor for acute recurrent pancreatitis and chronic pancreatitis in children that appears to act independently of genetic risk factors. Patients with PD and stones obstructing the pancreatic duct benefit most from therapeutic endoscopic retrograde cholangiopancreatography.
Collapse
|
30
|
Bogveradze N, Hasse F, Mayer P, Rupp C, Tjaden C, Klauss M, Kauczor HU, Weber TF. Is MRCP necessary to diagnose pancreas divisum? BMC Med Imaging 2019; 19:33. [PMID: 31035952 PMCID: PMC6489286 DOI: 10.1186/s12880-019-0329-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/27/2019] [Indexed: 12/13/2022] Open
Abstract
Background The purpose of this study is to compare the performance of three-dimensional magnetic resonance cholangiopancreatography (3D-MRCP) with non-MRCP T2-weighted magnetic resonance imaging (MRI) sequences for diagnosis of pancreas divisum (PD). Methods This is a retrospective study of 342 consecutive patients with abdominal MRI including 3D-MRCP. 3D-MRCP was a coronal respiration-navigated T2-weighted sequence with 1.5 mm slice thickness. Non-MRCP T2-weighted sequences were (1) a coronal inversion recovery sequence (TIRM) with 6 mm slice thickness and (2) a transverse single shot turbo spin echo sequence (HASTE) with 4 mm slice thickness. For 3D-MRCP, TIRM, and HASTE, presence of PD and assessment of evaluability were determined in a randomized manner. A consensus read by two radiologists using 3D-MRCP, non-MRCP T2-weighted sequences, and other available imaging sequences served as reference standard for diagnosis of PD. Statistical analysis included performance analysis of 3D-MRCP, TIRM, and HASTE and testing for noninferiority of non-MRCP T2-weighted sequences compared with 3D-MRCP. Results Thirty-three of 342 patients (9.7%) were diagnosed with PD using the reference standard. Sensitivity/specificity of 3D-MRCP for detecting PD were 81.2%/69.7% (p < 0.001). Sensitivity/specificity of TIRM and HASTE were 92.5%/93.9 and 98.1%/97.0%, respectively (p < 0.001 each). Grouped sensitivity/specificity of non-MRCP T2-weighted sequences were 99.8%/91.0%. Non-MRCP T2-weighted sequences were non-inferior to 3D-MRCP alone for diagnosis of PD. 20.2, 7.3%, and 2.3% of 3D-MRCP, TIRM, and HASTE, respectively, were not evaluable due to motion artifacts or insufficient duct depiction. Conclusions Non-MRCP T2-weighted MRI sequences offer high performance for diagnosis of PD and are noninferior to 3D-MRCP alone. Trial registration Not applicable.
Collapse
Affiliation(s)
- Nino Bogveradze
- Department of MRI, Research Institute of Clinical Medicine (Todua Clinic), 13 Tevdore mgvdlis St., 0112, Tbilisi, Georgia
| | - Felix Hasse
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
| | - Philipp Mayer
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
| | - Christian Rupp
- Department of Gastroenterology, Infectious Diseases, Intoxication, Heidelberg University Hospital, INF 410, 69120, Heidelberg, Germany
| | - Christin Tjaden
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
| | - Miriam Klauss
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
| | - Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
| | - Tim Frederik Weber
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany.
| |
Collapse
|
31
|
Sánchez Acedo P, Viteri Ramírez G, Herrera Cabezón J, Tarifa Castilla A. Intraductal papillary mucinous neoplasm of the main duct in a patient with pancreas divisum. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:322. [PMID: 30746953 DOI: 10.17235/reed.2019.5959/2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Pancreas divisum is a congenital anomaly present in 5-10% of the population and is usually asymptomatic. Pancreatic intraductal papillary mucinous neoplasms (IPMN) are mucinous cystic tumors that have malignant potential and are classified according to their location as IPMN of the main duct, branch duct or mixed type. Larger lesions and those originating in the main duct have an increased risk of malignancy. The real incidence is unknown as most lesions are asymptomatic.
Collapse
|
32
|
Capurso G, Traini M, Piciucchi M, Signoretti M, Arcidiacono PG. Exocrine pancreatic insufficiency: prevalence, diagnosis, and management. Clin Exp Gastroenterol 2019; 12:129-139. [PMID: 30962702 PMCID: PMC6432881 DOI: 10.2147/ceg.s168266] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Exocrine pancreatic insufficiency (EPI) is a condition caused by reduced or inappropriate secretion or activity of pancreatic juice and its digestive enzymes, pancreatic lipase in particular. EPI can result in clinical manifestation and biochemical alterations causing reduced quality of life and life-threating complications. EPI is common in pancreatic disorders, where it should be suspected and actively investigated, and in many extrapancreatic conditions. There are various tests available to diagnose EPI, with indirect, noninvasive ones, such as concentration of fecal elastase being more commonly employed. Administration of pancreatic enzymes replacement therapy remains the mainstay of EPI treatment. The present review article will discuss current evidence regarding the prevalence of EPI, the available tests to diagnose it and its treatment.
Collapse
Affiliation(s)
- Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy,
| | - Mariaemilia Traini
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy,
| | - Matteo Piciucchi
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Marianna Signoretti
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy,
| |
Collapse
|
33
|
Wang Q, Swensson J, Hu M, Cui E, Tirkes T, Jennings SG, Akisik F. Distribution and correlation of pancreatic gland size and duct diameters on MRCP in patients without evidence of pancreatic disease. Abdom Radiol (NY) 2019; 44:967-975. [PMID: 30600375 DOI: 10.1007/s00261-018-1879-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE To use MRCP to investigate age-related changes and gender differences of the pancreas and to correlate pancreatic gland size and duct diameter. METHODS In this institutional review, board-approved, HIPAA-compliant study, 280 patients (age 20-88 years) without a history of pancreatic or liver disease who had undergone MRI/MRCP from 2004 to 2015 were identified. The anteroposterior size and main duct diameter of the pancreatic head, body, and tail were measured. The pancreatic gland and duct sizes were compared between genders, and among seven age subgroups (20-29, 30-39, 40-49, 50-59, 60-69, 70-79, 80-89). RESULTS The pancreatic head and body were significantly larger in males than females (head, p < 0.01; body, p = 0.03), while the tail and the duct diameters of the pancreatic head, body, and tail showed no gender difference. As the age of male participants increased, there was an associated increase in size of the pancreatic gland initially (largest at age 50-59 (body) and 60-69 (head)), followed by subsequent decline in size thereafter. Additionally, the pancreatic duct diameter was found to increase gradually. In females, the size of the pancreatic gland decreased, while the diameter of the pancreatic duct increased with age. Moderate positive correlation for gland size and strong positive correlation for duct diameter among different pancreatic regions were found. Weak negative correlation was found between gland size and duct diameter. CONCLUSIONS There are gender differences in the gland size of the pancreatic head and body. The pancreatic gland size increases until the sixth decade in males, with a more continuous decrease in gland size with age in females. Both males and females demonstrate a marked decrease in gland size after the eighth decade. The duct diameter increases with age in both males and females.
Collapse
Affiliation(s)
- Qiushi Wang
- Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, No. 106 Zhong Shan Er Road, Guangzhou, 510080, Guangdong, China
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd, Indianapolis, IN, 46202, USA
| | - Jordan Swensson
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd, Indianapolis, IN, 46202, USA
| | - Maoqing Hu
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd, Indianapolis, IN, 46202, USA
- Department of Radiology, Jiangmen Central Hospital, No. 23 Haibang Street, Jiangmen, 529030, Guangdong, China
| | - Enming Cui
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd, Indianapolis, IN, 46202, USA
- Department of Radiology, Jiangmen Central Hospital, No. 23 Haibang Street, Jiangmen, 529030, Guangdong, China
| | - Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd, Indianapolis, IN, 46202, USA
| | - Samuel G Jennings
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd, Indianapolis, IN, 46202, USA
| | - Fatih Akisik
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N University Blvd, Indianapolis, IN, 46202, USA.
| |
Collapse
|
34
|
Covantev S. Pancreas divisum: a reemerging risk factor for pancreatic diseases. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2018; 56:233-242. [PMID: 30521477 DOI: 10.2478/rjim-2018-0022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Indexed: 12/30/2022]
Abstract
Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. The attention towards the PD has grown significantly since there are reports that this condition may cause acute relapsing pancreatitis, chronic pancreatitis and chronic abdominal pain syndrome. Furthermore, over the years, there have been multiple reports of PD associated with different types of tumors. There is evidence that PD can be associated with pancreatic tumors (up to 12.5% of cases). The golden standard for diagnosing PD is endoscopic retrograde cholangiopancreatography, but since it is an invasive procedure magnetic resonance cholangiopancreatography with secretin is a good alternative. In case the patient is symptomatic, endoscopic or surgical treatment should be performed. This review describes the key points of the pathophysiology, diagnostic modalities, risks of pancreatitis and tumors, as well as treatment options of PD.
Collapse
Affiliation(s)
- Serghei Covantev
- Laboratory of Allergology and Clinical Immunology, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Chisinau, Republic of Moldova
| |
Collapse
|
35
|
Marchegiani G, Andrianello S, Morbin G, Secchettin E, D'Onofrio M, De Robertis R, Malleo G, Bassi C, Salvia R. Importance of main pancreatic duct dilatation in IPMN undergoing surveillance. Br J Surg 2018; 105:1825-1834. [PMID: 30106195 DOI: 10.1002/bjs.10948] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/09/2018] [Accepted: 06/14/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The association between risk of pancreatic cancer and a dilated main pancreatic duct (MPD) in intraductal papillary mucinous neoplasm (IPMN) is debated. The aim of this study was to assess the role of MPD size in predicting pancreatic cancer in resected IPMNs and those kept under surveillance. METHODS All patients with IPMN referred to the Pancreas Institute, University of Verona Hospital Trust, from 2006 to 2016 were included. The primary endpoint was the occurrence of malignancy detected at surgery or during follow-up. RESULTS The final cohort consisted of 1688 patients with a median follow-up of 60 months. Main pancreatic duct dilatation was associated with other features of malignancy in both the resected and surveillance groups. In patients who underwent resection, only a MPD of at least 10 mm was an independent predictor of malignancy. In patients kept under surveillance, MPD dilatation was not associated with malignancy. Fifteen of 71 patients (21 per cent) with malignancy in the resection cohort had a dilated MPD alone, whereas only one of 30 (3 per cent) under surveillance with MPD dilatation alone developed malignancy. Patients with a dilated MPD and other worrisome features had an increased 5-year cumulative incidence of malignancy compared with those with a non-dilated duct (11 versus 1·2 per cent; P < 0·001); however, the risk of malignancy was not significantly increased in patients with a dilated MPD alone (4 versus 1·2 per cent; P = 0·448). CONCLUSION In patients under surveillance, a dilated MPD alone was not associated with an increased incidence of malignancy in IPMN.
Collapse
Affiliation(s)
- G Marchegiani
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - S Andrianello
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Morbin
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - E Secchettin
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - M D'Onofrio
- Department of Radiology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R De Robertis
- Department of Radiology, Casa di Cura Pederzoli, Peschiera del Garda, Italy
| | - G Malleo
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Bassi
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| |
Collapse
|
36
|
Abstract
Chronic pancreatitis is a syndrome involving inflammation, fibrosis, and loss of acinar and islet cells which can manifest in unrelenting abdominal pain, malnutrition, and exocrine and endocrine insufficiency. The Toxic-Metabolic, Idiopathic, Genetic, Autoimmune, Recurrent and Severe Acute Pancreatitis, Obstructive (TIGAR-O) classification system categorizes known causes and factors that contribute to chronic pancreatitis. Although determining disease etiology provides a framework for focused and specific treatments, chronic pancreatitis remains a challenging condition to treat owing to the often refractory, centrally mediated pain and the lack of consensus regarding when endoscopic therapy and surgery are indicated. Further complications incurred include both exocrine and endocrine pancreatic insufficiency, pseudocyst formation, bile duct obstruction, and pancreatic cancer. Medical treatment of chronic pancreatitis involves controlling pain, addressing malnutrition via the treatment of vitamin and mineral deficiencies and recognizing the risk of osteoporosis, and administering appropriate pancreatic enzyme supplementation and diabetic agents. Cornerstones in treatment include the recognition of pancreatic exocrine insufficiency and administration of pancreatic enzyme replacement therapy, support to cease smoking and alcohol consumption, consultation with a dietitian, and a systematic follow-up to assure optimal treatment effect.
Collapse
Affiliation(s)
- Angela Pham
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Christopher Forsmark
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| |
Collapse
|
37
|
Löhr JM, Panic N, Vujasinovic M, Verbeke CS. The ageing pancreas: a systematic review of the evidence and analysis of the consequences. J Intern Med 2018; 283:446-460. [PMID: 29474746 DOI: 10.1111/joim.12745] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Senior people constitute the fastest growing segment of the population. The elderly are at risk for malnutrition, thought to be caused by reduced food intake or involution of the physiological capacity of the GI tract. Age-related changes are well known in other secretory organs such as liver, kidney and intestine. The pancreas, representing a metabolically active organ with uptake and breakdown of essential nutritional components, changes its morphology and function with age. During childhood, the volume of the pancreas increases, reaching a plateau between 20 and 60 years, and declines thereafter. This decline involves the pancreatic parenchyma and is associated with decreased perfusion, fibrosis and atrophy. As a consequence of these changes, pancreatic exocrine function is impaired in healthy older individuals without any gastrointestinal disease. Five per cent of people older than 70 years and ten per cent older than 80 years have pancreatic exocrine insufficiency (PEI) with a faecal elastase-1 below 200 μg g-1 stool, and 5% have severe PEI with faecal elastase-1 below 100 μg g-1 stool. This may lead to maldigestion and malnutrition. Patients may have few symptoms, for example steatorrhoea, diarrhoea, abdominal pain and weight loss. Malnutrition consists of deficits of fat-soluble vitamins and is affecting both patients with PEI and the elderly. Secondary consequences may include decreased bone mineral density and results from impaired absorption of fat-soluble vitamin D due to impaired pancreatic exocrine function. The unanswered question is whether this age-related decrease in pancreatic function warrants therapy. Therapeutic intervention, which may consist of supplementation of pancreatic enzymes and/or vitamins in aged individuals with proven exocrine pancreas insufficiency, could contribute to healthy ageing.
Collapse
Affiliation(s)
- J-M Löhr
- Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - N Panic
- University Hospital Dr. Dragisa Misovic-Dedinje, Belgrade, Serbia
| | - M Vujasinovic
- Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - C S Verbeke
- Department of Pathology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
38
|
Dimitriou I, Katsourakis A, Nikolaidou E, Noussios G. The Main Anatomical Variations of the Pancreatic Duct System: Review of the Literature and Its Importance in Surgical Practice. J Clin Med Res 2018; 10:370-375. [PMID: 29581798 PMCID: PMC5862083 DOI: 10.14740/jocmr3344w] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 02/15/2018] [Indexed: 02/07/2023] Open
Abstract
Anatomical variations or anomalies of the pancreatic ducts are important in the planning and performance of endoscopic retrograde cholangiopancreatography (ERCP) and surgical procedures of the pancreas. Normal pancreatic duct anatomy occurs in approximately 94.3% of cases, and multiple variations have been described for the remaining 5.7%. The purpose of this study was to review the literature on the pancreatic duct anatomy and to underline its importance in daily invasive endoscopic and surgical practice. Two main databases were searched for suitable articles published from 2000 to 2017, and results concerning more than 8,200 patients were included in the review. The most common anatomical variation was that of pancreas divisum, which appeared in approximately 4.5% of cases.
Collapse
Affiliation(s)
- Ioannis Dimitriou
- Department of Anatomy in the Department of Physical Education and Sports Science (Serres), Aristotle University of Thessaloniki, Thessaloniki, Greece.,Laboratory of Anatomy in the Department of Physical Education and Sports Science (Serres), Aristotele University of Thessaloniki, Thessaloniki, Greece
| | | | - Eirini Nikolaidou
- Department of Surgery, Agios Dimitrios General Hospital, Thessaloniki, Greece
| | - George Noussios
- Laboratory of Anatomy in the Department of Physical Education and Sports Science (Serres), Aristotele University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
39
|
Epidemiology of Recurrent Acute and Chronic Pancreatitis: Similarities and Differences. Dig Dis Sci 2017; 62:1683-1691. [PMID: 28281168 PMCID: PMC5478431 DOI: 10.1007/s10620-017-4510-5] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 02/21/2017] [Indexed: 02/06/2023]
Abstract
Emerging data in the past few years suggest that acute, recurrent acute (RAP), and chronic pancreatitis (CP) represent a disease continuum. This review discusses the similarities and differences in the epidemiology of RAP and CP. RAP is a high-risk group, comprised of individuals at varying risk of progression. The premise is that RAP is an intermediary stage in the pathogenesis of CP, and a subset of RAP patients during their natural course transition to CP. Although many clinical factors have been identified, accurately predicting the probability of disease course in individual patients remains difficult. Future studies should focus on providing more precise estimates of the risk of disease transition in a cohort of patients, quantification of clinical events during the natural course of disease, and discovery of biomarkers of the different stages of the disease continuum. Availability of clinically relevant endpoints and linked biomarkers will allow more accurate prediction of the natural course of disease over intermediate- or long-term-based characteristics of an individual patient. These endpoints will also provide objective measures for use in clinical trials of interventions that aim to alter the natural course of disease.
Collapse
|
40
|
Patients with pancreas divisum have an increased risk of developing pancreatico-biliary neoplasms. Diagn Interv Imaging 2017; 98:99-100. [PMID: 28159087 DOI: 10.1016/j.diii.2017.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
41
|
Adibelli Z, Adatepe M, Isayeva L, Esen O, Yildirim M. Pancreas divisum: A risk factor for pancreaticobiliary tumors – an analysis of 1628 MR cholangiography examinations. Diagn Interv Imaging 2017; 98:141-147. [DOI: 10.1016/j.diii.2016.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/07/2016] [Accepted: 08/07/2016] [Indexed: 02/07/2023]
|
42
|
Gariepy CE, Heyman MB, Lowe ME, Pohl JF, Werlin SL, Wilschanski M, Barth B, Fishman DS, Freedman SD, Giefer MJ, Gonska T, Himes R, Husain SZ, Morinville VD, Ooi CY, Schwarzenberg SJ, Troendle DM, Yen E, Uc A. Causal Evaluation of Acute Recurrent and Chronic Pancreatitis in Children: Consensus From the INSPPIRE Group. J Pediatr Gastroenterol Nutr 2017; 64:95-103. [PMID: 27782962 PMCID: PMC5191966 DOI: 10.1097/mpg.0000000000001446] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Acute recurrent pancreatitis (ARP) and chronic pancreatitis (CP) have been diagnosed in children at increasing rates during the past decade. As pediatric ARP and CP are still relatively rare conditions, little quality evidence is available on which to base the diagnosis and determination of etiology. The aim of the study was to review the current state of the literature regarding the etiology of these disorders and to developed a consensus among a panel of clinically active specialists caring for children with these disorders to help guide the diagnostic evaluation and identify areas most in need of future research. METHODS A systematic review of the literature was performed and scored for quality, followed by consensus statements developed and scored by each individual in the group for level of agreement and strength of the supporting data using a modified Delphi method. Scores were analyzed for the level of consensus achieved by the group. RESULTS The panel reached consensus on 27 statements covering the definitions of pediatric ARP and CP, evaluation for potential etiologies of these disorders, and long-term monitoring. Statements for which the group reached consensus to make no recommendation or could not reach consensus are discussed. CONCLUSIONS This consensus helps define the minimal diagnostic evaluation and monitoring of children with ARP and CP. Even in areas in which we reached consensus, the quality of the evidence is weak, highlighting the need for further research. Improved understanding of the underlying cause will facilitate treatment development and targeting.
Collapse
Affiliation(s)
- Cheryl E. Gariepy
- Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Melvin B. Heyman
- University of California at San Francisco, San Francisco, CA, USA
| | - Mark E. Lowe
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | | | | | | | - Bradley Barth
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | | | | | | | | | - Ryan Himes
- Baylor College of Medicine, Houston, TX, USA
| | | | | | - Chee Y. Ooi
- University of New South Wales and Sydney Children’s Hospital Randwick Sydney, Australia
| | | | | | - Elizabeth Yen
- University of California at San Francisco, San Francisco, CA, USA
| | - Aliye Uc
- University of Iowa Children’s Hospital, Iowa City, IA, USA
| |
Collapse
|
43
|
Adibelli ZH, Adatepe M, Imamoglu C, Esen OS, Erkan N, Yildirim M. Anatomic variations of the pancreatic duct and their relevance with the Cambridge classification system: MRCP findings of 1158 consecutive patients. Radiol Oncol 2016; 50:370-377. [PMID: 27904444 PMCID: PMC5120578 DOI: 10.1515/raon-2016-0041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 06/06/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The study was conducted to evaluate the frequencies of the anatomic variations and the gender distributions of these variations of the pancreatic duct and their relevance with the Cambridge classification system as morphological sign of chronic pancreatitis using magnetic resonance cholangiopancreatography (MRCP). PATIENTS AND METHODS We retrospectively reviewed 1312 consecutive patients who referred to our department for MRCP between January 2013 and August 2015. We excluded 154 patients from the study because of less than optimal results due to imaging limitations or a history of surgery on pancreas. Finally a total of 1158 patients were included in the study. RESULTS Among the 1158 patients included in the study, 54 (4.6%) patients showed pancreas divisum, 13 patients (1.2%) were defined as ansa pancreatica. When we evaluated the course of the pancreatic duct, we found the prevalence 62.5% for descending, 30% for sigmoid, 5.5% for vertical and 2% for loop. The most commonly observed pancreatic duct configuration was Type 3 in 528 patients (45.6%) where 521 patients (45%) had Type 1 configuration. CONCLUSIONS Vertical course (p = 0.004) and Type 2 (p = 0.03) configuration of pancreatic duct were more frequent in females than males. There were no statistically significant differences between the gender for the other pancreatic duct variations such as pancreas divisium, ansa pancreatica and course types other than vertical course (p > 0.05 for all). Variants of pancreas divisum and normal pancreatic duct variants were not associated with morphologic findings of chronic pancreatitis by using the Cambridge classification system. The ansa pancreatica is a rare type of anatomical variation of the pancreatic duct, which might be considered as a predisposing factor to the onset of idiopathic pancreatitis.
Collapse
Affiliation(s)
| | - Mustafa Adatepe
- Department of Radiology, Urfa Balõklõgol State Hospital, Urfa, Turkey
| | - Cetin Imamoglu
- Department of Radiology, Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Ozgur Sipahi Esen
- Department of Radiology, Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Nazif Erkan
- Department of Surgery, Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Mehmet Yildirim
- Department of Surgery, Bozyaka Training and Research Hospital, Izmir, Turkey
| |
Collapse
|
44
|
Büchler MW, Esposito I, Grenacher L, Hackert T, Mayerle J. Precancerous Lesions and Carcinoma of the Pancreas. VISZERALMEDIZIN 2015; 31:53-7. [PMID: 26468306 PMCID: PMC4582694 DOI: 10.1159/000375245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Markus W Büchler
- Department for General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Irene Esposito
- Department of Pathology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lars Grenacher
- Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department for General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Julia Mayerle
- Department of Medicine A, University Medicine, Ernst-Moritz-Arndt-University, Greifswald, Germany
| |
Collapse
|
45
|
Budde C, Beyer G, Kühn JP, Lerch MM, Mayerle J. The Clinical and Socio-Economic Relevance of Increased IPMN Detection Rates and Management Choices. VISZERALMEDIZIN 2015; 31:47-52. [PMID: 26286668 PMCID: PMC4433134 DOI: 10.1159/000375455] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Increased usage of computed tomography and magnetic resonance imaging has led to a large increase in identified pancreatic cysts of up to 25% in population-based studies. The clinical and economic relevance of identifying so many cystic lesions has not been established. Compared to other organs such as liver or kidney, dysontogenetic pancreatic cysts are rare. Pancreatic cysts comprise a variety of benign, premalignant or malignant lesions; however, precise diagnosis before resection has an accuracy of only 80%. The focus of recent research was the malignant potential of intraductal papillary mucinous neoplasms (IPMN) with the aim of establishing clinical pathways addressing risk of malignancy, age and comorbidity, treatment-related morbidity and mortality as well as cost-effectiveness of treatment and surveillance. The focus of this review is to analyze the clinical and socio-economic relevance as well as the cost-benefit relation for IPMNs. Methods For analysis, the following MESH terms were used to identify original articles, reviews, and guidelines in PubMed: (‘intraductal papillary mucinous neoplasm’ OR ‘pancreatic cysts’) and (incidence OR relevance OR socio-economic OR economic OR cost-effectiveness OR cost-benefit). The retrieved publications were reviewed with a focus on clinical and socio-economic relevance in relation to the increasing incidence of IPMN. Results Addressing the increasing prevalence of pancreatic cystic lesions, recent consensus guidelines suggested criteria for risk stratification according to ‘worrisome features’ and ‘high-risk stigmata’. Recent prospective cohort studies evaluated whether these can be applied in clinical practice. Evaluation of three different clinical scenarios with regard to costs and quality-adjusted life years suggested a better effectiveness of surveillance after initial risk stratification by endoscopic ultrasound-guided fine-needle aspiration with cyst fluid analysis compared with immediate resection or follow-up without further intervention. Of interest, the ‘immediate surgery’ strategy was lowest for cost-effectiveness. Conclusions The increasing incidence of identified pancreatic cysts requires an improved strategy for non-invasive risk stratification based on advanced imaging strategies. In light of a malignancy risk of 2% for branch-duct IPMN, the socio-economic necessity of a balance between surveillance and resection has to be agreed on.
Collapse
Affiliation(s)
- Christoph Budde
- Department of Medicine A, University Medicine, Ernst Moritz Arndt University Greifswald, Germany
| | - Georg Beyer
- Department of Medicine A, University Medicine, Ernst Moritz Arndt University Greifswald, Germany
| | - Jens-Peter Kühn
- Institute of Radiology, University Medicine, Ernst Moritz Arndt University Greifswald, Germany
| | - Markus M Lerch
- Department of Medicine A, University Medicine, Ernst Moritz Arndt University Greifswald, Germany
| | - Julia Mayerle
- Department of Medicine A, University Medicine, Ernst Moritz Arndt University Greifswald, Germany
| |
Collapse
|